Gordon, Ai l orm 8-s.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
' 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 01
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. xri,egistered No. OS
Dist. No •5-6o l County- 16/ .... . e
e2 Or y (If city, give street dress)
Name of deceased .. l''L�
Sifigte, married, widOWed,
Sex... . Coloia' or divowced (writs the word)eZ ', Date of eath '4-'-- P'9 19
Age.. . Year` .3 Mont .. .Day '•s Birthplac .... ! — l
Cause of Death '
Certificate was signet v. .../Q '.
M.D
Address -,- i
Place of Burial (or - emov' }. . .. . . . .... .. ...... ....
(If body is to be tempo O"he , p later)
Cemetery kV ..' . . .... / Date of urial...... .... . . 1
(If body is to be temp rarity held. ii a space later)
The Certificate of Death c taining 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 acre the s r re 'stra 'on, ve recorded it in my Local Record with the abov to Registered
Number, the t f Y GRANT A PERMIT G2id 1'j�
to Q� ,0
(N ddress)
the to hold temporarily a .the body.
(Underta• r person h sing charge corpse) I ov ,or other ' di of[state I)
Dated 'i� . ....19 f (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the S u ject 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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