Zimmerman, Harry Form VS.Gt. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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..._._...5_. .._ . ..._.
Tiiwn
Dist. I�To. ttt..Ql..Countt....r4�� Village ctLi. ZOO
��
.1 aa..!
9. . —arCity (If city,give street address)
Name of deceased •
... B ..
� �Sin le, med, wi wed .._.//��� ��
Sex..i olor.Sa or divorced (write the word) Date of ath..o�J.GtY• /577te 19./../
Age a Years if Months to Days Birthplace
Cause of Death drx . to r
Certificate was signed . .4 M.D.
Address
Place of Burialor Removal)... . .-4e, � (xt.y ....... y�?..... .
(If body Is to h .ra 7 h '.fit In space
Cemetery...�i�. �n� ,rld/ i! Date of Buria wry -9l 19e.
(it body Is to be temporarily held,an In spate later) I
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
Number don the si ther I HE EBY GRANT A PERMIT
to.... te... . &. aSreeil-
_ : ddr .--/-
(Address)
the .. . . . to hold tempor and the body.
(t' risk or person bodily corpse) (1 .err or oth diaoose (state how])
Dated .A. 9...V-f (Signed).... (e( ,..... ..
Local Registrar
This Permit is sufficie for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
(*metery or other regulations), unless removal la by common carrier, in which case a Transit Permit (VS No. 62) is required.
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