Gokey, Arthur Form VS. 61. 8-16.35-50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr 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.
Dist. No. ared No. / 7
Town
County...!% ge-
�/ or City (If city, give street address)
Name of deceased. . ! ���"
Single, married, widowed, ,
Sex.-'21- Color dell' or divorced (write the word .Date of each. ... .. ., "5 19 c5 6
Age .7s.-- Years Months /r ays Birthplace .. ..
Cause of Death •- ..
Certificate was signed by .. • C.'. M.D.
Address ....
, ,{i
Place of Burial r emoval .
457
(If body is to be to ra 'y het 1 s ce later) S
Cemeteryy,l Date of B ial.... . 1
V6
(If body is to be temporarily held'.1 in space later)
The Certificate of Dea containing the above stated particulars, having been presented to me, after careful examina-
tion, 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 he basis,the of�IE�E/2,F�B�Y�T A PERMIT
to�. / ri""/ ."Prr `
,-z
(Name)
dress)
the to hold temporarily and the body.
*... uker o erso having charge of corpse) (Inter, remove, or otherwise dispose of [state how])
Dated. 19t� (Signed)
�� Local Registrar
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.
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