Borlawsky, Mollie NEW YORK STATE DEPARTMEN I OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VSF This Permit can be signed only by the Local Registrar (Deput ,, 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, LEGIBLY WRITTEN IN DURABLE BLACK INK. -r 2
— //``�✓ , Town, Village ° egiisstered No.
Dist. No.•'GC / County....[r1.'4-4 La-s' or City CC 4<-'�'-✓444 4 /`
7 . ? (If city, give street address)
3 �� � � Y
Name of deceased 1../r � t e...-' .i ,C x u^a Veteran '2 Ze ''
(If veteran, give name of War)
%%�� Single, married, widowed, / �j
SeaE.l ?� or divorced (write the word)27 Date of Death : 2 — S ... 19L4.t<
Age .2 Ye`ars. Months ,,,.Days Birthplace 1 fe {r. .f�
Cause of"Death....4:v Lz'1 i 1 G , . 4,./c' . ..:r ... ..GO' /...t.c::.c-.'72.44../
Certificate was signe ,y ,. l w cCtr.:- ,,.+` •7' �- M.D.
Address 7 :.. -L- ..• r-: -4C -6,.. .7/4
Place of Burial (or Remoya�l) (.. :i.:F v. /Burial
(If body is to be porarily held,`1111 ' s at�
CemeteryG el
:' , " Date 7 19
(If body is to he temporarily. Id, 6I I space later)
The Certificate of Bath containing the above staled 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 accepted the same for registration, have recorded it in my Loc Record with the above stated Registered
Nwnber, and on the basis thereof I HEREBY GRANT A PERMIT "7.
to_.712da�-.r '. .Z: .� ciit.:i.! 14<L";./../:
the �.���� t;�- �{Name) ddress)
! ;.r...,. to hold temporarily and .�jd the body
(Undertaker or person having charge of copse) (Inter,re ve, erwise pose of [state how))
Dated ..i2— 'Z 7 19&.,7 (Signed) ,?rram ioc1R gistrar
This Permit is sufficient for the Removal (and Interment or Creemyyya Ion a body to any- art of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) is required.
Form VS. 61. (Rev. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of was —__ 19_
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Lot Na.__ 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," 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.