Gilchrist, Alice Form vs.EL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ur 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 Registered No._ .._...._....._._
'II Village
Dist. N* 42 Cou�lty.f. /i- T r:41 Ei% or City etiy--/c /-, J
2 (If city, give street address)
Name of deceasedV "I C /2 CG u 6 oh'917 �t C Cf/(1r i Veteran
Single, married, widowed, tit veteran, give name of War)
Se l 7' cr.- Coloi�Li/N(....c:..or divorced (write the wordy N4 Ri it D Date Death... / - G - 19 5 4
Age .7 0 Years ' Months .r... .Days Birth/place i_^' R t` S'' 'T' •
Cause of Death...... 1 "/If.11 C I"PAS L -�l1l.. F ?c-% ,°^l - l)l/9 gg--rf t17 e<<<./-7-,,
Certificate was signed by N. AiZ Ca M.D.
Address ( ! .. L L i= �•y
�j
Place of Burial (or Removal)....�1 �./-it q -S' GY
(If body is to be temporarily,held,flllAnikDace later) 7 i co
Cemetery..rJ. 4%-v-4r-YAI `- I or1 r7 -c/zi Date of Burial f 19 s
(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
Nu ber, and q7 the asia thereof I HEREBY GRANT A PERMIT �/
to.F' Ci i`'' ' c G'/7/9T� V-..I'q,y S' /airc /✓ e (//)" N< ( ( _ t fv.7 .
(Name) ' ��� (Address)
the to' to hold tempora ' y and the body.
ndertaker or person ving charge of rpse) 2(�ater,remov se disnose of[state how])
Dat . h:
� ir� 19... ..(2 (Signed). .. 1/01�/'l�
,,�"— Loc *stetter
Permit is sdff'icient for the Removal (and Interment or Cremation) of a bogy to any part of the State (subject to local
cemetery o- other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSNNENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
.,
Date of r t i,. ky,•7' was G��w �' , 19
(Interment or Cremation)
(Name of Cemetery, Crematorium,ietC )
Section Lot No.// '7 Grave No. c'
•
(Signed) ,`/'7%'>y1 C- 1e (-c(
(Peredn in charge)
Address '/ t �/ ,, • `� .�. . G/. � ✓l ��
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 DIRECTOR 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.