Shapera, Samuel Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Its. 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 ITTEN IN DURABLE BLACK INK. Registered No.
;Int611
Town ?3.Q ��
Dist. No 5 ... :' oun Village .0 /'4/ ....
�, or City P city, giv stfeet address)
Name of deceased.. ,�. . . .
j .. Single, married, widowed,
Sex.... ..Color... .. .." •-. r`divorced (write the word)`1 --��J7� Date of ath. .... . .. ....L4....19 ,
Age....>� e Years...16:../ ,. .Months .1..3 Da Birthplace..
Cause of Death.... . „I.. . .. . .... . - . . .. .. .. irt.
Certificate was signed by... /`Gf ,... ... .... .... . .. ... ,,,,e .,j .,,,
al
Address G
Place of Bun (or Remova ..... ..
(If body is to be mporaray held, n ace er) .� /
Cemetery._ .... Z�y............ .. Date of Buria ,1 19.
(If body is to be temporarily held,fill space 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 LA
I hay accepted the same f registrati , have recorded it in my Loc I Record with the above stated Registered
Nu r, and on �sis hereof I GRANT A PERMIT �_ /-
to ..�. R�(�
N (, ���'� e ✓ (Address)
the .to hold tempo ' and e body.
( 'n o person via charge o c.o tse) titer,re ove, erwis • 5” [state how])
to ... ... ...19.. 7 (Signed) /4
..... . . . . .. . : ... ..
Local Registrar
This er it is sufficient for the Removal (and Interment or Cr o a o o any part of the State (subject to local
cemetery other regulations). unless removal is by common carrier,in whi case a ansit Permit (VS No. 62) is required.
5.
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