Kantrawitz, Rebecca Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT °Y
ta This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (To .?
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF 17,a F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Register ..__ !
'ftWir `fi
Dist. No.0OL.Gounty` 'W tna� ( � 4e �f•
/� � IY city,give street address)
Name of deceased , _ .. .... ...... .....t./. . '' r-
` C,��ingle, married, widowed, L4 , _ : /J }' i
S of' or divorced (write the ord) s'u'�- Date o ! ath + 19... ..
Age . 7. 's,Yg�a . ., M„.nth ,p /,Day f ,�$'rthplace.
!�l�r�r i�E�[.f
Ouse of Degh . ;..< ,. •
a
CertiAcate was signeckb .. .. . •
Address r k:.�.
Place of Buri. (o f emov'al).... - ...4 «'
"R'
(If body Is to bet ly h 1 a '� , • i
A'
Cemetery v k.... .. �... . Date of Burial.. .1940
(If body?1s to,be ,•rrrily>he t),fill in apace later)
'The Certifi f of Death co staining the above stated particulars, having been presented me, after careful exa.mi-
nation; the same appehring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same fo •'s tion, ve recorded it in my Local Record `th the above sta Registered
Numb i d on the b- ,is .' HE Y GRANT A PERMIT
to ' r •
j' > ss�f.
the .... j.J. to hold tempor ' y a • the body:
s :ker or perm). ,harge o orpse) # In e,or othe se di®aese,of[state howl)
Dated. . - - 19.. i. (Signed) .. ....... . •
...�. .. ...
0 d o Or Local Re tray
This P is sufficient for the Removal (and Interment or Creme ion)/f a b• to any part of the State (subject to loco
cemetery or.• I. -r regulations),unless removal is by common carrier,in which case a ransit Permit (VS No. 62) is required.
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