Goldstein, Morris NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rg' 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. 9 `?—
�7� �l Town, Village R istered No. /
Dist. No. �/ �� County `2' ar-C-i4y tg-e C--i.4.0- 2....1
If city, give street address)
>22
Name of deceased 612, -4:-4 Veteran 'U
(If veteran, give name of War)
Single, married, widowed, �`
Sex . ).,p,_,, or divorced (write the word) Date of Death .... // 19/0
Age 7 i Years � .M the Days Birthplace R -rt.(
Cause of Death a-Gt
Certificate was signed by ti el /Y L •
/l /YCJih./17 J M.D.
Address (5*` J d1•. -�� o -- ,, 7J - /..1,f-e,
Place of Burial (or Removal %~ n
�.tnrn •
(If bodyis to be temporarily tticin spa ater) r
Cemeteryp y ( ' p. , A/ • 7 - Date of Burial `/ 19 7,5'
(If body is to he temporarily held, fil�f 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
PERMI `2
... ........ .. .
( me) / (Address
the to hold temporarily and ...�.c,tti the body
(Und aker +r per on avg charge of co ,gg) Inter, remove, ory�therwtse dispose of (state how))
Dated //�a/14 , / 19 .1 (Signed) .... - A . Cocal .Registrar
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any 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) (3A2-323)