Berman, Gussie Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
12r This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No....._.,L . ..__
-Town--
,^1
Dist. No.d L °/ Coun !/�r ge. ..,{.!� /2'a¢( JT/"a f
or City (If city,give`treet address)
Name of deceased S5/e el'�?gez T•
cc // Single, married, widowed
Sex..TGr4i4rColor W4ifc or divorcAd (wte the word) Mu't" 1 Date of D th....JaN l,, P a^1'9.2
Age 6'.4 / Years /P Months " Days / Birth lace 5.,�/..Q.
Cause of Death / k✓'.t►? G! l.�rl g sty i ' i r
Sty J ,�
,yc
Certificate was signed by 4........ ,a, / T
Address ear/ ,� / U `M D.
Place If Burial (or Removal
(If body is to be porarily head fl in pace later)
Cemetery . Ai;�1n. (!emeIS Date of Burial I v4 C) �..P 19,61.
(If body is to be temporarily held,fill in space ter)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
and on the basis f I HEREBY GRANT A PERMI
Nugibex �h�o
to F•4?:ke. .. • 5 t ker)%� t le.!l� !.IN.S.C.. e w\�I 'k •
%, (N ) `Address)
the ,.�.1!t•s�t=1: A1s7 tC to hold temporaril and h�'�1^ the body.
ertaker or person having charge of corpse) nter,.remove,9ryth ow])
Dated .. ..41..9 19...4.7 (Signed) l-f {
Local Registrar
This ermit is sit.,cunt for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regud-bons),unless resessval is by common carrier,in which case a Transit Permit (VS No. 62) is required. ,
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