Ginsburg, Sara Form vs 61. 6-8-34-50,000 (17-7 01)
YEW YORK STATE DEPARTMENT OF HEALT
OFFICIAL BURIAL (OR REMOVAL) PERMIT
mar This Permit can bf signed only by the Local Registrar (Deputy or Su':,registrar) of the Primary. Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND CC MPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITT3N IN DURABLE BLACK IN{.
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Dist. No.... '. 1.. J's 'stered No.
W11
County /_ yn Village
�9�f ity(If city, 've street adl3ress)
Name of deceased w �7 7 1
�— Single,married,widowed, '�
Sex /� ..Color ,�� or divorced (write the word) Date of ...,/ 19
Age... _.... .Birthplace. r LP Yeal's....._...������nths D s p .......�...�
Cause of Death _._..... ... ..... � -
Certificate was signed b y „ 77 M.D.
Address I ;. , K r . . i i �i�o i
Place of Burial /of Remy ��
(If body /�is `�"�"be tem at.'' held,I'd ' ace la )
Cemetery �r �'� � Date of Burial 19�r
(If body is to be temporarily held,fill in spailater)
The Certificate of Death containing the above stated particulars, having been presented to rre, after careful examina-
tion, the sam-appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted/the same for regi tration, have recorded it in my Local Rec ;with the above stated Registered Number,
and o3r--the-basis ther y!)f HEREBY G A PERMIT
( ess) •
the......._.: _....L...._ to hold terrporaril the body.
.�. .. ..
(Un r or per laving charge of corpse) t , 0 moist 9isp a jstate how]).
Dated 19'`fa (Signtd).. �' �`� "`�'
i .,• Local Regisesr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to •r y part of the :tate (subject to local cemetery
or other regulations), unless removal is by common carrier, in which k.ase a Transit Permit (VS No. 62) is rvguired.
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