Gifford, Milo Form {N.Cl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tl 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.
Town
Dist. No3.:g.i.Fqq..County VflTage ..r<.,--e---c-,....t-.c,.
yyyy�� /J � or-Eitvn (If city. give street add )
Name of deceased c(.l..l.�-4P ![.� r,l,.n.r(re'i-A.,.4.
Single, married, widowed, nn /� L n tit
Sedirl Colorer divorced (write the word) otalSQ,. Date of Death.(1 7 194.g.
Age Qa Years 9 DSpnths is Days _ Birthplace.fXeCttfl .,,!X ..k7c..t,.+..ttatP'�"ty
Cause of Death ((h,
Certificate was signed by �` yN� Qf�rp - t M.D.
Address '4n&c44 :9'f - -Mt7 W
Place of Burial (or Removal) le:M ....o.�- St-in w:!ehrg
(If body Is to be temporarily held,fill later) " ' t �"
Cemetery l W-<-5 Y)t(f.Y\. Date of urial..0-�( j /0 19.. �.
(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 he 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, don the b is t reoR HEREBY GRANT A PE MIT � /f rr.-,(( IL.. �jr
to 1.... . i..2.,t•36a G .. (.f .?4.r?',
p ( 'ame) (Address)
the Altai
t' to hold temporarily and the body.
(Urrtatet or pe7n baying charge of corpse) (1st{}, om ve.2r otherwise ells se of(state how))
Dated -4 19.11/...I. (Signed)... . .. �-I.+./.., er IIS�
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem ion) o • body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carder, in hick ase a Transit Permit (VS No. 62) is required.
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