Lurie, James `;AlnItEan Y3 SW.oa. s-a-aa-a wavy *a.-vo..... _''
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
eirThia Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra.
ego District(Town,Village,or City)in whisk the den creeemed after the FLUacceptance and of a COR.
POET AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No..... S-GJ
County---.-•. - _--... 01:•r,����� 0# ate of Death..._'!S!. -- . ..._---- II—
Town
,Vil- .�✓. /'4,a l - .C ��
lage,or City-
) Age...- Corr__
(If eitY.give street address) (O/�Mos.) • '•=a efige—1(6111-6
Cause of Death.._.._ _.ef,_ t^i!
Place of Burial(o emoval) .-_••
-G ;
n�JL� •
Cemetery Date of Burial—. __._
Certificate of Death . ..._______
Gave oaf deoeaeed)
having been presen to me containing the above stated particulars and after examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS RE UIRED BY
' LAW I have accepted the same for registration,have riled it in my Local with
the toil Regis 4 btu b.r„1 a the basis I HEI .BY A IT
�---- ' 1 �`''_" ..,
(Name
the.
Undertakes charge sp. _( - os°iv/.�'' ,
•Da __-•--_ aj%
Local Reg:aims
This Permit is sufficient for the Removal (and Interment.r Cremation of a to part of the
State
m(subject to NAlGc\�te y or other regulation), unless removal to by common ,in which case a
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