Gilman, Nora }.-rm TS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Zr 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 CERTIFICA1X OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered l a /s
`U "Lawn
Dist. No.:.5 � County C 44- Villagt.. 4 , '
' City (If city,give street address)
Name of deceased Z1-4-121
M Single, married, widowed,
Sex - ... ..Color..: .. .or divorced (write ty,e word) ..Date of th. iii....0 0 19.W...
Age .60 Year,, Months.. Days Birthplacee'I d ,. ,..I/•...
Cause of Death •
Certificate was signed by M.D.
Address t I
Place of Burial (or Removal) .
,(If body is to be porarily he 11 in-space later) �/!
Cemetery 4.a4-... Date of Burial 1 �� .7r3 19.,7!°,.
(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
Num , and on the balip thereo I HEREBY GRANT A PERM
88) //
the to hold temporarily and . . tiG the body.
(U a1Kor or perso a ng charge o orpse) /�, e ove,or erwis of to how])
Dated �,iy�� .�1�.( 19.j��..e (Signed)
G Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the S ate (subject to local
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