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117 EAST MAIN STREET
ELKTON, MARYLAND 21921
This is to certify that the insurance hereinafter described has been effected with
National Indemnity Company
Omaha, Nebraska
Insnrea Fishers Island Fire Department and the Town of Southold
Aaaress Fishers Island, New York 06390
Sponsoring Committee Same aS above
Address Same
Location of display '{lest Harbor, Fishers Island, N,Y,
Date of display Julv 4 or 5 1966
Contract price of display
CERTIFICATE OF INSURANCE
Sponsors Risk Certificates not valid without contract price
Policy No. OLT 35605 Date
4/4/66
to 4/4/67
Excess limits effected with
Excess policy No. Date to
LIMITS OF LIABII,ITY
Bodily Injury Property Damage
Each Person Each Accident Each Accident Aggregate
Base Limits 50,000 100,000 50 000 nil
Excess
Total Limits
NOTE: Policy covers Subdivision 5 of section 1894-a penal law of the State of N,Y,
In the event of rain or inclement weather prohibiting any display previously reported, coverage will apply on the ponponed date on which the
Displays are held provided Notice is forwazded.
It is hereby uvderrtood and agreed that mvecage under this policy is limited Co accidents arising directly from the Fireworks Displays only.
In the event of any material change in or cancellatOn of said policies, Jenness G Company will make all reasonable effoct to send notice of such
change or cancellation to the certificate of holdec at the address shown herein, but Jecmess E Company assumes no responsibility for any mirtake
or for failure to give such notice. Nothing herein contained shall be considered as in any wise modifying any provision of said policies.
Coverage afforded to exhibitions which are reported to Insurance Carrier prior to exhibition date, ONLY.
Serial # SR 6607-1
Dated at Elkton, Maryland this 21st day of June 196 6
Signed C7'
Tot 11L~tT K. RSC7ilCin, Tpl>< CLSRIC, TAIq of ioDTH1R.D
11PPLIG-Tlf~lf Ii HiRiiY Ni1D>Z, pursuant to the psa~+isioni of
isetion 189ha of the Penal Lan of the hats of xw York, for a permit
to display tirenorks as hereinafter apecilied~
/~ Tke display is to be spoasered by Fjs~-CRS ~SL/-! NU
f~/zC''/il~r ,With principal o!lice at /-"/S/~~KS Zs~.4~/U
11w 7h+rk, asd Hill he held ea ~~ 4 T N, , ~C/ L / ,196 6
(day) (s~ontlsj
at ~, a 0 l.M..
rn~~
yhe toilwi.nq persons are to he is charge of th. actnai
shootiaq of the tireermeka~,
_~ ~
sxrsRZ>~c~e
Licensed
dewolition.
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fireworks
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Albert Chaplaski 49
Frederick Perkins 1
Leo Valentina 51
Excellent
n
n
and type of firworks is as foliwst
ll~asaorted aerial fireworks
----- M--M----yN-NNMM- -NM-N--MM---M-MN~---M--NN
-M~---M-N--N--N-M-M~.N-- N-~1-N-N-A-- M-Mr1/~-/~N~-
----Y.-I~~YN-W--MM-----N-N- MN--~---N-~M.~-A-1~--YMNN---M
-W--M--N-------~-----N--N ---NINN---NM-------N---------
The firenoarks Hill he stored in a covered uncle prior to
tlu shootLW on the yronnds,
]-ttached herel~o and aade a part hereof is a diagram of tl-a
grousds oa Which the display is to be held. Also attached is the oertif-
icate or poliep of insurance coverags.
Dated June 15, 1966
Respectfully sul~witted,
Fishers Island Fire Department
(nw of org sation~-
G~~~u- ~
.GO
w
at Fishers Island, , xw York.