Walczak, Stanislaw NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ra- This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. C�
/! Registered No. /
Dist. No.....?-(1 / County... ./.4.ep&A., or or City 62.Z d.1( / ..4 .
(If city, give street address)
Name of deceased ....5, ;01.U/..5,�!9. J....GNA.LL'ez..rk& Veteran i,.%rt/<
(If veteran, give name of War)
Single, married, widowed,
Sex .... .?>- 1, or divorced (write the word) ' .aitd Date of Death .. 9:23 19
Age....45...7 Years .Months Days Birthplace �r.;'.dd
Cause of Death ../ReW3. ?.4.,.ig.ie...e,R: uAclanll}...fi P- 4..,41.c..415'
Certificate was signed by ......',tJ.....� rt �..... 5!YNtn M.D.
Address e,2 .....CR.:�.4 ...•....1...��Q =.�xilc°... .. .,...41..y,
Place of Burial (or Removal .. � ��
(If body is to bedtemporarily a d, i in ace aterj
Cemetery „. .-ees.-2..... ..t.2..u1 Date of Burial , -,1 -,7 19 •
(If body is to he temporarily held, fill 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 �� � /
ame) d�ressj
the .. to hold temporarily and ( the body
(Undertaker or person having charge of corpse) ( , remove or oth se po a of (state how))
Dated 7.. .7'-7_5 19 7, (Signed)
alf e�gtstrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Perm' (VS No. 62) is required.
FO9tM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of // '/ 19 7' 7:
waCsa (
(Interment or )
le
(Name of Cemetery, CLectiaat-4)-
1(Section Lot Lot No. /_31
Grave No.
(Signed) '
(Person in Charge)
/
Address ,z <- (
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date
person is in charge, the FUNERAL DIRECTOR or UN -
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Regiqr
of District in which cemetery is located.
SEXTONS, FUNERAL DI RECTORS and UN DERTAIRS
violating the law relative to the return of permits are liab to
a penalty of NOT LESS THAN FIVE DOLLARS NOR E
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.