Ormsky, George " NEW----n
YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
a 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 CER
Registered No..7PirTE OF
DEATH, LEGIBLY WRITTEN URABLE BLACK INK.
Dist. Noiag dan.--Count edn - la
_Yill4ge—S;246 -C-0?
ity (If city,give street address)
Name of deceased...-- . gl
1.7 71' 5
Date .
-12/7741
likie, married, widowed, 4 •
SexAZ-4 Color .or divorced (write he word). of ath Z___tte 19.,,,/
Age 6-41 Years. / Months Da .s • Birthplac . 51,aciefearr.777.7.A9C.A....
I
Cause of Death
Certificate was signed by M.D.
Address erg.2i
Place of Burial (or Removal) 47-rd a -Wja c-0, ..
at body Is to berbiraroclileyeace 179., dee..e.
Cemetery Date of Burial egatosal'i Trra 19e.2.
(It body I.to be temporarily beld.MI In space later)
The Certificate of Death containing the above'hated particulars, having been presented to me, after careful exami-
nation, the same appearing to he COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for egistration, have recorded it in my Local Record with the above stated Registered
Numbnfind on theasis reef I EBY GRANT A PERMIT
to *--iiinette..,,,C.. 147-41
, me C) • (Address),...
the 6./e) to hold temporarily a d the body.
(U er or pe )41vInsalpargestcorpes) Inter. r ov eriagenosen,bowl)
Dated i—ea-4 19.n4 (Signed) ,
• Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS blo. 62) is required.
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