Lanzon, George Form VS.81. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t2r 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.
Dist. No'ct'AP County 44""."- "- Village. 4 '
Or City (If city, give street address)
Name of deceased . !0-7 a-7-1-
-],� Siagie married, witivWtd,
Sex /"/'��! Color W os. iverced (write the word) .kA Date of Deg 4 19.142
Age...1G7..f Y ars.... ..... Months Days Birthplace ,' R . -G.t....-.
Cause of Death.... 144...... ..
Certificate was signed by _Ast le.14.111:11.‘:.:47:11.1°,:aderila"--
M.D.
Address .:. i
/t-ero�L�
Place of Bui ial (or Removal) . . . . . .... -et4u1y►
(If body Is to be temp
held, 1 i e c ter
Cemetery !YT Date of Burialfrl--rs.‘- 9' 19; 3.
(If body Is to be temporarily held,fill in pace later)
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
Numi4e1, and on Is thgy f I HEREBY GRANT A PERMIT94 014 ..0..7
./ �' (Name) ss)
the K.4 ,!!�• • - to hold temporarily and .. .... .. the body.
Tndertaker or person having charge of corpse) (Inter, e,9rotherwise dispose of [state how])
Dated. . 19k .,. (Signed) eifir f/ . .
7 Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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