Gerstin, Edward NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qg' 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 WRITTEN IN DURABLE BLACK INK.
/4 Town, Village
` Registered No. ,342.7
Dist. No. 6ei County L{/ �Vt-r.,,J or City /
(If city, give street address)
Name of deceasedAc-4--"a-2-4. ' Veteran h^.%
(If veteran, give name of War)
Single, married, widowed,
Sex hip or divorced (write the word) Date of Death, ��? 19.7.a
Age Years 3.2/`osj Month Days Birthplace 'ems/.."`at.,
Cause of Death r ^
Certificate was signed by 4 `- yl, M.D.
Address ri .Place of Burial (or RemovalII S-w� ✓(If body is to he to porarily heill 1 spac later) .
Cemetery n- ,��,�y t Date of Burial 7"-3� 1976
(If body is to be/temporarily el , ll in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT '�'�-�//gy�ppe I� Q / / �O
to 7�1 ' ? i.,,._. , -. 6c 77�c-e�/,t2'. e4 D.'x2L �`i
(Name) / / (Address)
the to hold temporarily and the body
(Undertaker o person having charge of corpse) (I% remove, or otheyyvise dispose of (state how))
Dated �Z 19 c c
r7 (Signed) � Q.e.,„
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (9A2-205) • ;f<L,0