Goss Jr, Nelson Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. Registered No...�1.9.7__..___.._
Town
Dist. No...5 01...County Warren Village Glens...Fal1s...I3osp3.tal.
or City (It city,give street address)
Name flc8eceased Nelson W. Goss Jr.
Single, married,widowed,
Sex Color.Wq. Q...or divorced (write the word) litirtgla Date of Death July..15 19...39
Age..9---- Years Months g$ Days Birthplace Glefts...F..e.11.a,....N.... Y....
Cause of Death MaLautritioxt — 20...l aya
Certificate was signed by Dr.... .... M.D.
Address Q1,.9.116... 'a 1, .13 s...RA. I.,
Place of Burial (or Removal)....Queensbui'ij/..:....N....Y....
(If body is to be temporarily held,fill in space later)
Cemetery Pain) V is Q.e w atery Date of Burial JU1y...17 1939...
(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 exami-
nation, 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 HEREBY GRANT A PERMIT
to 0t.'914...C:...,S: ,ar `.ord Glana.Ealls.ad�i.3�..
(Name) a
the UXI$e.rtaker to hold temporari ter the body.
(Undertaker or person having charge of corpse) I remove, se dispose of(state howl)
Dated 19 (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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