Gehring, William Form y6.Si.
NEW YORK STATE DEPARTMENT OF HEALTH '
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK_ Town Registered No.__.. 0..._
Village (4c
Dist. No ,) 6�l county. 4.f 4k.Z1 or City t.r
n _ (It city,give street/ address)
Name of deceased �C:fr �-6-a- I --✓ Veteran ih-r /
� � ingle, married, widowed, (If veteran, give name of war)
Sex J, Color ' br divorced (wnte the word) ...f .‘/Date of Death , f� 19. .
Age .6.........Years Months Days B' lace /.? al•C : ..Ji. �•
�
Cause of Death �E "�Y��j,-�.,�., r::� .. .... . . .. •�.�. C�� �.�t " .�s�:�. . .
Certificate was signed by M.D.
Address ... ...lG... f........:.
Place of Burial (or Removal) .. .�� ,••• • • /•••_ '
(If body is to be tempor rily,held,fill in space later)e-
Cemetery 1%7a .: ..:21,% Date of Burial 19 S 7
(If body is to be temporarily held,811 in space later)
Thq 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
Number on the basis thereof I HEREBY GRANT A PERMIT l
to :4� Z A = ,.as% d v� �� ....,
GJ -. .4 k) 't: (4ddree.)
the �'i' % :Y' to hold temporarily � the body.
(Undertaker or rson having charge of cor ) to otli se dispose of[state how])
Dated ...2... // 19.. .::7 (Signed) . di -�-,.--'
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTFIIMEiTS OR CREMAWIS
ARE MADE
Date o -,f" JCS ;1 /( 19
(Interment or resat1on)
l�/ 74
(Name of Cemetery, Crematoria®, e tc.4)
' ,,....,
Section i; - 7 Lot No. 7 Grave No.
(Signed)
(Person In cha ge)
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 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.