Berkowitz, Hyman NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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.
/heze:istere No. -2-21
Town, Village
Dist. No._Ste)/ County •(-.,2 anAl---Ps-,—. or City
....v.^ (If city, give street addresY''s ,
- ..------ ,
Name of deceased Single, Veteran
(If veteran, give name of War)
married, widowed /. . i
Sex .L.PLAL-, or divorced (write the word), leVA.s.of.e1,4"4-"- Date of 1Death ,.3 0 7C
Age yi) . Yearct M -,--
ont Days Birthplace
Cause o Death 12.-4,•“-e..4,...
, •
Certificate was signed M.D.
Address 3.2 att...11._ - ,CLee,..,14,-, •---/-el---47 11
Place of Burial (or Removal) , .
(If body is to eorarily .4110%;.. ,a ater
Cemetery / .4, Date of Burial Pliti ‘71 19 7- ,
(If body is to he tempheld, fill ,,,, 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 a registra-
tion, have orded it in my cal Record with the above stated Registered Number, and on the b sis th eof I HEREBY GRANT A
PERMIT ar_ztuL,
to ) ,ec„-ut.A 1, 15.4( 1,4, t.0.4-c /0 6i j_i_Za Ay
4 11.4_ Name) (Aclress)
the to hold temporarily and % the body
(Un er or pets n having charge of corpse) (Inter, r , or otherwise dispose of (state how))
Dated 19 7L, - (Signed) .. ,
- 8 Aso
This Permit ' sufficient for the Removal (and Interment or Cremation)of a body to any p of the State (subject t local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS o. 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 of was 19
(Interment•or Cremation)
•
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in,Charge)
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registr
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
violating the law relative to the return of permits are liable t
a penalty of NOT LESS THAN FIVE DOLLARS NOR MOR
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.