Zishink, Edward Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERT FIFS TE OF
DEATH, LE e Y WRITTEN IN DURABLE BLACK INK. Town Registered No. _.b.a.._.....__
ID
'�' ( Village
Dist. I�ro... .t2.�..�..Courlty....1�1 � �`� or City ')
. �, Q� (If city, give street address)
Name of deceased E ... . . . . ... . . ti��t!KiC�. Veteran
n j I Single, married, dowed, (If veteran,jive name of War) r
Sex..h.G ..ColorM'—'"""or divorced (wnte the word) Date of Death. .Qfr. /, 19 �-1
Age tp.. ....Year .Months g.. ..Days Birthplace
Cause of Death ...� .. . . � �
Certificate was signed by O�.+vw.lC. ... �
,,,. M.D.
Address "' �� ��//JJ
Place of Burial (or Remo al) LS.f A. % "? )11
(If body is to beStnporarny h ll ace later)
Cemetery to--- Date of Burial a� 19..,f.:.r"
(If body Is to be temp y he in 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 LAW,
I have accepted the same for registration, have recorded it in my Local Record with
ther.et.t., re above stated Registered
Number, on the basis reof I H REBY GRANT A PERMIT
to ge2. ( ) ddress)
the to hold temporarily and the body.
(Undertake or person having charge of corpse) titer, em ,or oth wise dianose of [state how])
Dated Q�.�„�l / `14 19d.-r"--- (Signed) .
al II
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Seats (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date of L
, was ! t'.;� / 195 S
(Inter ent or Cremation)
)1.44....4.4„, Talr- a-44A ,."-"\14'1)14--,91)(12 A1-7(111°4—
(Name of metery, Crematorium, etc.)
•
Section Lot No. Grave No.
C)SCI
(Signed)
QLS
(Person in charge)
Address 7 � �� i.h.,,,,c:Yota
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS: and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT'LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFrm.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.