Novack, Ida Frrm VS.61. NEW YORK STATE DEPARTMENT -OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itr 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. RegistenA No
Town Dist. No 4-6 0 1Count6 ViIIage :S . . .I.t '..
J or City (If city,give street address)
Name o dieceased eee///
d;::--
Single, married, widowed
Sex pColor...... .... r divorced (write the word).... ... .. .. . Date of ath ....5 19.4.o2,
✓• f
Age Y r I Months
—
ays Bi place.....
Cause of Death...... /�A ?9.11.4... ,
Q.;.. ua e.G.ti, 64
Certificate was si ed by.... - �(, M.D.
Address
Place of Buri 1 (or Removal). ' 7) Pr
(If body is to b emporarily , fil n sp a later)
Cemetery.. . . Da of Burial 1(4444- / 19(If body is to be temporar ly held, I in space later)
The Certificate of Death containing the above stated particulars, having been pres to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same for regis ration, hav recorded it in my Lo Record with5e above stated Registered
Num , and on the .)et they HEREB T A PERMI
todicaeg/ '74,(,./
a e ( ddress)
the to hold ten-Tor ' y an ee—body.
(Un r ker or person lydvi arge a of rpse) ter, remo of snore of[ to ho
(fl ,
Dated...1. 19. (Signed)
Local Registrar
This P it is sufficient for the Removal (and Interment or Crematio of a od o any. - -- -��-- ---1-•'----` ---'--.. ■ . part of the State (subject to local
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