Wilensky, Jacob NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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. 3�
449
Registered No.
Town, Vill e
Dist. No. / " County �, or City ``'` V.: /V. 64If cireet address)
Name of deceased- . Veteran
(If veteran,give name of War)
�, / Single,married,widowed,
Se .�4�..r.. or divorced (write the word) l�•ee�vrt`� Date each • !V 19
Age 9? Ye s . Months Da s Birthplace s
Cause of Death Zi 'nu-P`4..J 0._.
Certificate was signed by (�� �- -- M.D.
Address Ga elf
Place of Burial (or Removal �7 9
(If body is titleorarily held, fill in space ter)
Cemetery Date of Burial. /� 19
(If body is to be temporarily held, fill in space later)
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 recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GRANT A P RMI;T
to _ i'/„�/ -. fir- 7
pp,�f (Name) Cress)
the,�-l a, S to hold temporarily and the body
(Unlertalce or perso havingsharge of cor �,..- nter remove, or oche wis ispose�,pf ( tate how))
Dated ! S 19 0 (Signed) X'�'�
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ' ct 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) (8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was 19d
(Interment or Wa"I tj')D)
r �
( me of Cemetery, oeeefirtart
LLff �� ��jj.
Section Lot No. bGrave No.
(Signed)
(Person in Charge)
Address rG �
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.