Zbozanski, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ear 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.
�!/' R to No. ...
SI6G
Town, Villa (I � r '�j�
Dist. No., t County.... .. ... or City 4IC
f ci , the s ee addr s!
s)
Name of deceased Veteran ..........4'
(If veteran, give name of War)
Single, married, widowed, /
Sex ... _, or divorced (write the word) ... Date of Dea 1 �(�� `3v 19 �.T
, .,.,
22
Age Y .Month .. ys Birthplace `yl
Cause of Death
Certificate was signed y . . .... - M.D.
Address ' 7.4.f.e4/ Ve.)-,...- .)
Place of Buria r Rea oval , i
(If body is to b to porarily he d, fill ace atei)
Cemetery .,Q�»,., Date of Burial /�
— 319� '
(If body m he is to teporarily fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same . .pearing to be COMPLETE ORRECT, AND SATISFACTORY AS QUIRED BY LAW, I have accepted the same for registra-
tion, ve recorded it ' y Loca ecord,,with the above stated Regis Number, and on the basis thereof I HEREBY GRANT A
PER
to ....
i /r
a ) / /
.4Aclaress. ,
the to hold temporarily and . , . . ..., the body
ndertaker oripirson having charge of cor se) (In a move, or otherwise dispose of (state how))
Dated .. cA,..................19 (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an art of t...: State (su je o local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit S No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date oF4 Z`fit Gwas / y 19
(Interment or-€semac un}
(Name of Cemetery,
(4i �1 C
Section Lot No. X-4—jte Grave No.
(Signe A <!1 1
(Person in Charge)
' � ''
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNQE -
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge," an
FILE PERMIT WITHIN THREE (3) DAYS with the Registra ,
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER
violating the law relative to the return of permits are liable Al
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORB4
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.