Mesnick, Dora NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. k y
��0 ( Town, Village �� �� ��red No.
Dist. No. / County ''�/ --) or City "
r (If city, give street address)
Name of deceased )2t- -c-sr Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) Date of Death ° ..7 19
Age 7 Years/0?-�26-1-8 Months Days Birthplace f-
Cause of Death s a... 44-z-
Certificate was signed by .....f ..... M.D.
Address / ye,-..,..�..a.:C�,Q,
Place of Burial (or Removal) .... . ............
(If body is to be temporarily held, fill in space ra r L .-`......
Cemetery .. / Date of Burial -/0 - S 19
(If body is to he temporarily held, fill in space ater)
The CERTIFICATE OF DEATH containing t e above stated particul rs, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORREC , 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 q C
to /(2(-c-Ze.;_d-4-.- "y )2-(_K1a-
(Name I (Address)
the to hold temporarily d `// 4-(. the body
(Undertaker or person having charge of corpse) l (Inter, tam ve, o otherwise dispose of (state how))
Dated �? - l3 19 ...7:S--- (Signed) Y O
Locr;Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t..e. 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)