Gurney, Helen Torn) ,.:. Ki. NEW YORK STATE DEPARTMENT OF HEALTH „c x
OFFICIAL BURIAL (OR REMOVAL) PERMIT
le 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 WRITTE�DURABLE BLACK INK. Regist ed No... 7
/
T-ero7fr'
Dist. No 6�i0( Cc>untti. P�*kr�i`�/7 e...>� 4�t, . ' A 4 / '
/��C�� A G{!... '!3F C1tV (If cite, ire street address)
Name of deceased // `.c. ,r'/
Sex f/ j �j�ngle, married, wido ed, //L ,/L
.: . for i�7 'n'' ' divorced (write the word) Date of t�LlGi"—' ei 197. .
Age Year, 'Months l.7.Days irthplace /st[�+C�r. . .. ....
Cause of each . c49*•-t alCer4
Certificate was signed ;,_ - ,, .D
Address 74 4f
Place of Burial (� r Removal � Crl. .. . . . ... . ... ..., Atize_ca...7
(If body is to be to r:frily held, till in ) later)
Cemetery -F Date f Burial �19..�j�;
(if body is to temporarily liel . lill in space later)
The Certificate of Dea containing the above stated partic rs, having been preseo me, afterful exami-
nation, the same appearing to he COMPLETE, CORREC . AND SATISFACTORY .AS REQUIRED BY LAW,
I have a epted the same for r- :tration, have recorded it in my Lo 1 Record with the above stated Registered
Numbe and on th bth eo, I EBY GRANT A PERMI
to /-
'a*. (Address)
the ...... .. ... .. - '' to hold temporari., nd the body.
(C, taker or person having charge of corpse) r re ov �ooy�o e r ose of(state w])
Dated 19..1/ (Signed) N,
Local Registrar
Thi /ermit is sufficient for the Removal (and Interment or Cre a y to any part of the State (subject
cemetery or other regulations),unless removal is by common carrier, in w ch case Transit Permit (VS No. 62) is rely.
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