Kaplan, Rose 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. _
Registered No. ._. ,,j..�
, ) Town, Village
Dist. No. `1 U/ Tty_W�j.A or City % If city, give street address)
Name of deceased------- -___.I\__ ___ - - Veteran
If
(If veteran, give name of War)
Single, ma ed,widowed,
Sex T It-�A or divorced (write the word) � ¢, - Date f Death 19•7
Age Yea s _ Months Days / Birth ace
Cause of Death ,! ,�.� .A-4".t -`1 � - .V,5L -i.o.
Certificate Addresss signed by ,e % ce " it M.D.
_:,�
Place of Burial (or Removal) `�--ct.At.y )'('--•-7
(If body is to be til 1por rily held, fill in lat r) `
Cemetery ___= --- �Lm Date of Burial 77ll 19._-
(If body is to be tempo arily held, fi in space ter)
The CERTIFICATE OF DEAT 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 registr on, have recor ed it in my Local R ord with the above stated Registered Number, and on the ba 's thereof I E E-
BY GRA A RMIT
ton 43 4 ,�
Name (Add ess)
the -�h..-rcL -• to hold temporarily and � % - the body
(Unlertaker or person aving charge of corpse) (lnt remove, or otherwise dispos f (state how))
Dated 7 // 19...A (Signed) cc • �
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body 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.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was 19
(I ter)ment or Cremation)
f /i :th fi
(Name of Cemetery, Crematorium, etc
Section Lot No. Gray No.
(Signed) \ \4j
(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
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.