Silverman, Eva Form VS.8L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIFICT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.
Dist. No.rs`TP.Qf f.
....County ,2/GZP�tr,./ Village4.
or City (If city,give street address)
Name of deceased L
' "f Single, ma ied, idowed, ,
Sex C.J 'J Color t-`a • or divorced (writee word). .. . Date of Dea .. . . . ..019 ,3
Age /1 Y rs.... ..._../..Q Months Days Birthplace
Cause of Death .. .
Certificate-was signed -by- - M D.
Address � aa��rr�� 27,,0 .
Place of Bu;ial (o Removal) l:.�!..P-12.--,.. . . lL te,,, 4
(If body is to be tem ar:ly hel , fil p e ter
Cemetery.. . ✓� Date of Burial .jp 19..70
(If body is to be temporarily held,fill apace 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 re 'stration, have recorded it in my Local Record with the above stated Registered
Num and on e a 's the f I H R Y GRANT A PERMIT
to 4 e y.....27 .,
Nam ddress)
Dated. ,�? 19..the to hold temporal' nd t e body.
( rtaker or person havin arge o e se) ter,re e,o• erwis of [s a ho )
. (Signed) ]
ocal Registrar
This Permit is suffic ent for the Removal (and Interment or Crema ion a bod to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ansit Permit (VS No. 62) is required.
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