Diskin, Jacob 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 CER-
TIFICATE OF DEATH, LE IBLY WRITTEN IN DURABLE BLACK INK.
?? Town, �� R stered No.
Dist. No: . Coun ' G (Fr-Eitr
(If city, give stree ress
Name of deceased - ... Veteran
(If veteran, give name of War)
Vak, S' gle, married, widowed,
Sex or divorced (write the word) �. ate of ,.,C • 196, C
/
Age 21 Y s _. Mon t)r s / Da •rthplace ,,
Cause of-Death 1i1i.
Certificate was si ned.by ... . < . .. _. D.
Address... ' /� ' 1 0, 1
Place of Bu ' 1 or Remova .. AT -
(If body is to b oraril held, till 'n I e` .4 6 �/
Cemetery.... y ' Date of Burial - / 7� 1C.fp
(If body is to he temporarily held, in space 13r)
The Certificate of Death containin the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ted the same or registration, ave recorded it in my Local Ito d ith the_bgv stated Registered
Numb r ,r,on the basis L.re f I HER Y GRANT A PERMIT
,�,,,� 2—
•
f+ e) ` $ , ` '(7tddress)
. to hold tempora it id * _. the ody
the......... ... ..1.... -_
■n rta r or person aving charge of co e) (Inter, remove, or ise d' pose f [state how])
Dated . ....../... 19 (Signed)
Lo -egistr
This Perm t is sufficient for the Removal (and Interment or Cremation) of a bo 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. 6l. (Rev, 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of . was 6 / q 19
(Interment or Cremation)
''-w-
(Name of Ceme ry, Crematorium, etc.)
Section Lot No. Grave No.
r
(Signed)
r /
(Pe on in Charge)
Address. 1 ? (1 .- tee_
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," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict in which cemetery is located.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law
will be enforced. Local Registrars are required, under penalty,
to report violations thereof.
,1111