Gordon, Kathryn Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit can be signed only by the Local Registrar (Deputy or suhregistrar) 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 Registered No._... .6
Dist. No..s..>!Q.� ,_ Village ,��
County.. .� 1...�xa:��2.... .. or City �..�e�uc.�..... ���"�-fir
(If city, give street address)
Name of deceased 7J ., .. 4'" L Veteran �-e-'
in married widowed
` ,�S g �� (If veteran. give name of War)
So -ei!t1—s,C;olor...!' �e--4:r divorced (wnte the word) rC, Date of th Z 3 19..,S.--S
Age '��.�..G Year A Mo ths.....2..4. ...Days • Birthplace..,c�or Y y -7-7 ...........
Cause of Death.,. ..
Certificate was signed,by ,. �.. / M.D.
.. .. .. . .. Pre("1—i
Address .1,Z.. ..Place of Burial (or Removal) „ „
(If body is to be tem arily h d, 1 ace later)
Cemetery ! .4.... .. �5`Date of Burial .. r 196-6—
(If body is be temporarily he ,'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 ac ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, the basis theregf I HEREBVGRANT A PERMIT
to . .... . .":“...:X: 747. 1... ... :�^� ?'rk::�:_:.. 4 /---
•/ (..ams) dress)
the �1 -�:‘ .?.�ac .z,.- to hold temporarily an . . T the body.
(us ertaker or person having charge of corpse) .11(Ltter,zioove,or therwise dispose of(state bow))
Dated iaf , f -- S`19.. ,S"' (Signed)
Local Registrar
This Permit is an cient for the Removal (and Interment or Cremation) of a body to any pert of the State (.abject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
ENDORSE ENT OF SEXTON OR PERSON IN CHARGE OF
PRE6fISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was `4. 2 C 19 c
(Interment orZP ten)
1( .
(Name of emete , re torlux, etc.)
Section L t No. Grave No.
(Signed) AIWA C4(....4-e bZeide#4 ,
(Person in charge)
Address
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOE or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.