Zayachek, Martin M W TURK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
iSr 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 74
No.
Dist. No. 1�/ Town, Village ---It-,(�C'/ County or Citysiz_47egister
•o._.
If city, give street address)
Name of deceased *. � 7 Veteran y.� •• LfJ.../L--
(If veter n,give name of War)
-lyJ� /J Single, married, the widowed, Q J2 / Ct
Sex ._. /`�GI�J� or divorced (write the word) 'Lt-t-d Date of Death 19.1.`_7.
Age _...(� Years _ . Months Days Birthp ce .__ 'l-- __
Cause of Death .:.-�
Certificate was signed by _._. . _-aa.�.o fjy
M.D.
Address . r-z- �� 0. '`
Place of Buri (or Removal) c a
(If body is to be porarily hel ill s ce} r) � •
Cemetery 1�Z f 21/---- • Date of Burial-.nt', c.-_-7 19__-7_J
(If body is to be temporarily held, fill in space er)
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 registration, have ecorde it in my Local Reco with the above stated Registered m er, a on the basis t;ereof I HERE-
BY G 40 A PERMIT
to --- - ---' . ,
( me) (Add ss)
i
theia to hold temporarily and ' +`-ct--*- • the ltely
(Unler ker r p9rson awing charge of corps (Inter, rem. ; or otherwise dispose of (state how))
Dated f�' 19-/7 (Signed) `,e glsts�tQ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body t any part of the S a e 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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON W'VHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of 'u� was + / 19 /7
(Intermentt or cremation)
(:?L'irl-e- ' I r
(
(Name of Cemetery, Ore lathar u eic 1
Section Lot No. Gr e
(Signed) a
(Person in Charge)
Address ), // 4 r .
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
UNDERTAKER 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 District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.