Schwartz, Abraham PERMIT FOR DISPOSITION OF HUMAN REMAINS
NAME OF DECEDENT SEX DATE OF BIRTH DATE OF DEATH
ABRAHAM ISAAC SCHWARTZ Male 11/12/1919 11/16/197 8
PLACE OF DEATH—CITY OR TOWN PLACE OF DEATH—COUNTY (OR STATE IF NOT IN CALIFORNIA) NAME AND ADDRESS OF SPOUSE OR OTHER INFORMANT
Los Angeles Los Angeles Moe Schwartz
NAME OF FUNERAL DIRECTOR (OR PERSON ACTING AS SUCH) I CALIFORNIA LICENSE NUMBER
4 Queensbury Place
Malinow & Silverman Mortuary i F487 Glens Falls, New York
/�� TYPE OF PERMIT. CIRCLE ONLY ONE OF THE FOLLOWING TYPES OF DISPOSITION
1. BURIAL(INCLUDES ENTOMBMENT) 5. DISINTERMENT AND BURIAL (INCLUDES B. DISINTERMENT AND REINTERMENT OF CREMATED
�/ ENTOMBMENT) REMAINS (INCLUDES INURNMENT)
2. CREMATION AND BURIAL (INCLUDES INURNMENT)
6. DISINTERMENT.CREMATION.AND BURIAL
3. CREMATION AND BURIAL AT SEA OR DISPOSITION (INCLUDES INURNMENT)
OTHER THAN IN A CEMETERY(AS PROVIDED FOR IN 9. DISINTERMENT OF CREMATED REMAINS AND BURIAL
HEALTH AND SAFETY CODE) 7. DISINTERMENT.CREMATION.AND BURIAL AT SEA AT SEA OR DISPOSITION OTHER THAN IN A
OR.DISPOSITION OTHER THAN IN A CEMETERY CEMETERY (AS PROVIDED FOR IN HEALTH AND
4. SCIENTIFIC USE (AS PROVIDED FOR IN HEALTH AND SAFETY CODE) SAFETY CODE)
FOR THE PURPOSE OF ISSUING THIS PERMIT. DISINTERMENT IS DEFINED AS THE REMOVAL OF HUMAN REMAINS FROM ONE SPECIFIED PLACE OF DISPOSITION TO ANOTHER SPECIFIED PLACE
OF DISPOSITION. COMPLETE EACH ITEM REQUIRED FOR THE TYPE OF PERMIT SPECIFIED ABOVE AND INVALIDATE EACH LINE NOT REQUIRED FOR THE SPECIFIED DISPOSITION.
NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED I COUNTY
BURIAL
Shaaray Tefila Cemetery; Queensbury, New York i Queens
NAME AND ADDRESS OF CREMATORY WHERE REMAINS ARE TO BE CREM.3TED LATE CREMATED SIGNATURE Of PERSON IN CHARGE OF CREMA1ORY
CREMATION NA NA , NA
INTERMENT NAME AND ADDRESS OF CEMETERY WHERE REMAINS ARE TO BE INTERRED COUNTY
AFTER
CREMATION NA j NA
BURIAL AT SEA ADDRESS. NEAREST POINT ON SHORELINE. OR OTHER DESCRIPTION SUFFICIENT TO IDENTIFY FINAL PLACE AND COUNTY OF DISPOSITION
OR
DISPOSITION OTHER
THAN IN A CEMETERY
OF CREMATED REMAINS NA NA
This is to certify that I am the person having the right to control the disposition of the SIGNATURE OF APPLICANT
ACKNOWLEDGMENT remains of the above named decedent under provisions of the Health and Safety Code, ' NA
OF
APPLICANT and I hereby acknowledge that trespass and nuisance laws apply and understand that DATE SIGNED
this permit gives no right of unrestricted access to property not owned by me. NA
SCIENTIFIC NAME AND ADDRESS OF FACILITY RECEIVING REMAINS
USE NA
LOCAL
REGISTRAR THE CALIFORNIA HEALTH AND SAFETY CODE AND IS THE NOV 19 THIS PERMIT IS ISSUED IN ACCORDANCE WITH PROVISIONS OF AMOUNT OF FEE PAID DATE PERMIT ISSUE SIGNATURE OF EG R ISS G RMIT
1913
AUTHORITY FOR THE DISPOSITION SPECIFIED IN THIS PERMIT S C `Ill-AA
CERTIFICATION l SIGNATURE OF PERSON IN CHARGE OF SPOSITION
OF PERSON IN CHARGE I CERTIFY THAT THE SPECIFIED DISPOSITION WAS MADE ON '
OF DISPOSITION (ENTER DATE)
COPY I OF THE PERMIT ACCOMPANIES THE REMAINS TO THE STATED PLACE OF DISPOSITION. THE PERSON IN CHARGE OF DISPOSITION IS RESPONSIBLE FOR COMPLETING THE PERMIT AND FORWARDING THE COM-
PLETED PERMIT WITHIN 10 DAYS TO THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH DISPOSITION OCCURRED OR TO THE LOCAL REGISTRAR OF THE DISTRICT NEAREST THE POINT WHERE THE CREMATED RE-
MAINS WERE BURIED AT SEA.
COPY 1 STATE OF CALIFORNIA—DEPARTMENT OF HEALTH—OFFICE OF THE STATE REGISTRAR OF VITAL STATISTICS (REV. 4-1-75) FORM VS-9