Shapiro, Samuel Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 alter the FILING and ecceptaace of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 15.13 i"
Dist- Nc 7.Q/..count Q '.goil., ...,.(14 .7.taege . ...
. or City (If city, give street ad ss)
Name of deceased..
``',�, Single, married, wid ed, � " �
Sep Colo: .t!G ! e- divorced (write the word).",.[ef.4141 .:........Date of 1'G¢-1 /4 ..7fr..19.7r�
Age.....4r...D Years / Months -?1i. Days Birthplace ..G.Kr
Cause of Death.... -
Certificate was signed by M.D.
Address es"J,
Place of Buri (or Rem val)... Ir.L,t�7fi,.
(If body is to be mporarily Ill ace later) ,/ LL
Cemetery. ... ...� Date of Burial..' / 7 4I4r 19 ` 0
(It body is to be temporarily held, 11 in space later)
The Certificate of Death containing the above staled 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
Numbe and on asi thereof I ER]EBY GRANT A PERMIT 7
.Brest)
the to hold temporaril/. ,i•I y1 i
di ti body.
ndertak r . )
Dated.7� l3. , 19 (Signed) � � •
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su.'• t to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is r:•uir ..
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