Grishkot Sr., Walter NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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,CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. C/�
S/ Town, Vill /' egiste No
Dist. No. ``‘ ( County . L_,,iail,it.kr ___ tty.. ' �`Zisji
/' , (If city give stre`e't1ddre s)
Name of deceased (� ( '�n j,,A.e .._ ... � 1 Veteran — w C0 ...�
Singe
/ (If veteran, give name of War)
ied widowed
Sex ,_•.,.., . or dilvor edr(write the word) (/ i1 Date of Deat j. 19 /�
Age .Ye M s Days Birthplace...
Cause of Death ✓
Certificate was signed b .. .. M.D.
Address .... .... )7Y
. .., f c!% '� .....t
21)
Place of e
1 (or Re oval ....
(If body istempor i y he d, li t ace aterj
4� .... Date of .* 19(If body 1s fe11f`po ly heTti;fil space late
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same a pearing to be COMPLETE, CORRE T, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, aye recorded it in my Local Record •ith the above stated Re istered Number d on e is thereof I HEREBY GRANT A
PERM _Jy ��,
(Na ) a (Ad res
the . . (sj. z,c.. to hold temporarily and the body
(Unde to•er o5erson�having charge of c.grpse) ( , remove or erwt e spose of (state how))
Dated II// ///l 19 ••.fI,TU (Signed) cx —�
Local istrar
This•Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of th 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) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
-�-'%ti i4 /g
Date of C was. "0/19 I
(Interment or ice tma ion)
/,f--i-t-() K--e e
(Name of Cemetery, Cseapatoriumrtx..) - --
di
Section � Lot No. c . `Grave Na
(Signed) L.'vr, /l.! !f v , ,
(Person in Charge)
Address /g c— i ,/-,l'r.sti ��l'�"1 .
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 District 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.