Green, Samuel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar 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. --„
Registered NoL4. ( )
Town, Village
<-41 n I
Dist. No. ..--dbiv '', f County, 661.(2,114.Z.IcA-) or City -e,---72-•".....,A.m.
/, (If city, give street address)
.,,N,64„r,/,,f_04 ,1:
Name of deceased •Iieteran
(If veteran, give name of War)
'-*/... .-er--- _-.'
.. Single, married, Widowed, • -c) i
Sex d
or divorced (write the word)--71,,,--a...444-44( Date of Death- / , ' F 19 73
_
Age ,37/ Years.7- , ,,.Months Days Birthplace . (....
Cause of Death (2.74' ' ' L
P-fr---7444-44,e.d24-1- kjy.L-e-A- 61,
Certificate was signed by .)2- A.,_ j M.D.
Address 0 ,,...44-4- ,;_,----cze-f..-.-..,. .-e4, )3 7 / 2- U 1
7 •
Place of Burial (or Removal) , '4.-?...--4....49P,.“15.-- -e-ei,-:-- 7 y2 .-C1
(If body is to be held, fill c:_ire,,LL
,-emetery ... . 4411 ' Date of Burial r(-)/7 19 73
(If body is o he temporarily held,jill i sp cc later)
The CERTIFICATE OF DEATH contain ng 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, ha )recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
r
PERMI ' „66,44..ere.„‘ Ce--e- '
- 414
-e--
the ....a.....-6..i...,-4--- - ...e,——C-P.----4-ffl-* 1...e.' .ri to hold temporarily and .) the body
(Un ertaker or kers71having charge of corpse) (Inte emove, yhhery di ose of (state how))
Dated /V / -7
/ ( 197 4
3 (Signed) ... . .
"al l'er&ra
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an 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) (A2-248)