Gifford, Byron Form VS 61. 6-8-34-50,000 (17-7901)
NEW FORK 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No.95-6 f5,7 Registered No.
Town
County '1 ../..2./. -Village..
(If city,give street add s) -
Name of deceased
,Single,mar d,widowe ,
Sex/ Q-Ql Color.......... or divorced (write the word).-(� .. . . .. . .... Date of eath....,1 r. .. .... ... 2.s 19..E..:
Age Ye s. Tvlont �a Days Birthplace
g
Cause of Death .�Y. .. ....
Certificate was signed by - f j/ - , M.D.
Address 7I
Place of Bur'.l (or Removal) C,C. ,
(If body is to be /m+. arily ld, pace later)
Cemetery ... Date of Burial I 'tP� 19.. .�a
(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 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,
andCC (Name)on the basis there f EREBY GRANT A PERMIT YleA-"c19--A-j4dress)
the to hold temporarily the body.
rtaker person having charge ns cyyrpse) (Inter, uove, oth wise dispose of[state how))
Dated.. Me
. .... • 2. 19.0 i° (Signed),
s Loc egistrar
This Permit ' sufficient for the Removal (and Interment or Cre'l.n oay any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Tr it Pert (VS No. 62) is required.
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