Silverman, Bennett Form %S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VT This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tows
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI1 r
DEATH,.LEGIBLY( y. .�iu.
WRITTEN IN DURABLE BLACK INK. Registered No
Dist. No.,JTO/ Count //� s
... � a �,. (.....
(If ci , give street address)
Name of deceased ........ v .
/i0 Single, married, widowed, e7 ' �d
Sew... .... Color lr�/ or divorced (write h word) Date of D •r/ 19
Age .,5 �"ear �u. 0 1 �.7 D s Bir lace "
Cause of Death
` t.
Certificate was signed by .F
Address...
Place of Buria sr Remov ' ... h,. , �.,(
(If body is to be tG. porarily fill i) : /J,,I. later)
Cemetery `: I Date of Burial /�,�{�.rC..� ,17-1 19.X
(If body Is to be temporarily held,li`fin space later)
The Certificate of Death co taining the above stated particulars, having been presented to me, after careful exami
nation, the same appearing to he COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW
I have accept the same for re •fation, hay- recorded it in my Lo R rd with the ove ated Re istere<
Number, an n the basi e ir HER�'1'/GRANT A PERMI
to ,_. / / .
the se)to hold temporaril ..the body
(tiro rt er or per ba ing charge of corpse) , remove,or of vise se of eta w
Dated ,.� 19. .1�'" _(Signed).... ..
II/ J Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State subject to lea
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