Gunn, Franklin Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 CERTIpytTE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. .:7
village
Dist. N0,5ia/ County /1 1,77-1-4-1.-. Town „czer,,,74,:z_ ";,,,,w''
o• 5 City
(If city,give street addresi
Name of deceased f' .‘:: .
Single, married, widowed,
Sex .a4. .Colori6Z4.or divorced (wge the word)Altazet Date of Death. . .i' 4 19•KI
Cause of Death Years ,e---e. ontlas. _,.:.... ai,74,vaD s • Birthplace
Certificate was signed h)„,.'....-:-- ,i.k4:1,•IsW,x-e. .. ...:.... .. . M D
Address
Place of Burial sr Removal) 44--xecvor:m5g/- 01
(If body is to be e ,:orari held, fi I in space later)
Cemetery.. 0.. . . , .. Date of Burial.. iar:-22.-,...T./ 19. :
(If body Is to be temporar tlild, fill in space later)
The Certificate of eath containing the above stated particulars, having been rented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acçspted the same for registration, have recorded it in my Local Record with the above stated Registered
Number d on th......HEREBY GRANT A PERMIT
to. ‘ _
(„72,efee,:e. (Address)
the to hold ternporaril the body.
(LT maker oil n having charge of c,xpee) o erwise dispose of[state how])
Dated... ys 19. ,7 (Signed) , ,----'
LocaYltegistrar
is Permit is sufficient for the Removal (and Interment or Cremation) of a body to a y 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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