Gifford, Ward Form %o.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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............_..__.-..__.._....
Dist. No.,./ f , County ,, Tow•
n
age,
. City/ (If city,give street address)
Sexte of4 deceased
Co or�rL� Si d v, marr - 4
g fed, widowed, ��ry�
.. .... (write the word)...`ka: /2.a..d,(.....Date of Death 'tag- .. t../... 140
Age 9...4' Years �,��.//. .Months J...Qt. Days //'' __ Bi�j PPlace.... 1-1-r-'--`-`F' '
Cause of Death ate.� rt d2 re.....C-.1'�h-f-cet-d- 1 --r �
Certificate was signed by Iss-.4 c,. Y 1.... 'Xr�an.t.2. .•. ID.
Address l...9.--: "�
Place of Burial (or Removal) `BLS b. `. l •t
(If body Is to be temporarily held, Ell in sees later),
Cemetery ';,�' C Date of Burial....witaa-....1.,.2 I 19i..4
(If body Is to be temporarily held, Ell 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 ' k: ,
,(Name) (Address)
the ti 'LL.(' to hold temporarily and ,� the body.
(U'bdertaker or persop kerb!,charge of cgorpse) (Inter, remove,or otherwise dlapose of(state how])
Dated . 19..1:..0 (Signed) 4 4
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crc.,,.ltion) 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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