Pearlberg, Samuel 4rna is.fIl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local RegIstrar (Deputy or subregistrar) of tita 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._ ..42L___.
Dist. Nom(UV County 00.4-1(4.4rx..; kiagen—e 1. -4.-/g-cf Axe?, )aarpo-fek,Name of deceased... adardweeele. alai‘,..
Single, married, widowed, ore!? (If clty.give street address)
• •
Se.)?frik WO or divorced (write the woataitice Date of poit1:-.2kretted.2.5..19.0."
Age 7/ Years.. /a . Mo ths / /.: ;..Days • . Birth e.....C.It •••• • •
Cause of Death.r.044are .. . .. . . . . ...A.r.fiegy. .. . ....
Certificate was sl ed by- -222 • ..., M.D.
Address
Place of Burial (or Removal) Calettled .atensa 2 ..,. 27..4,"
(if body is to be porarliy Eel On In ce'Merl--
Cemetery Date of Burial. 72aelte-te' oed 192e/
(It body Is to be :warily held.fill In space later) ,
The Gertifica e of Death containing the abo e stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
4 have accepted the same for registration, have recorded it in my Local R49ord wi . the above stated Registered
Na s' ' and on the basishereof 1 t
( ro ) EBY GRANT A PERM .43sic
I /Pi
/ , dasiSP466
the de to hold tempor • and the body.
i.E;Irtraladrw000priog charge nt corpse) MS 0 )1., ereltrenr2:beiLxtera ho
Dated 19.g7 (Signed)
W/ Local RegIstrar
This Permit is sufficient for the Removal (and Interment or Cremation) of b to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which ease a Transit Permit (VS No. 62) is required.
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