Gillmett, Lehaloud 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ,
Registered No. ,..,? 7 X
o Town, Village f �
Dist. No. S� ( / County LC) C:�:^.v.:Li--r`4.-f• or City 4 -- r
(If city, give street address)
% �) �--
Name of deceased ' j�..G"e :d'.ee t -t-C,<'j'LQ`:f••.•••• eteran
(/ (If veteran, give name of War)
Single, marri d, widcFvlied,
Sex -;a!L.:C;d.::: % !1�.. l or divorced (write the word) i <- Date of Death ...�-. ..�.y�, /7 19/3
Age :.i` .' Years Months Days ff , Birt lace "! ' y
Cause of Death ..•f�-�' r.ta -eeLL.:.c.:i....a:' • '' ` ' o�� ...L .r�Q
l
Certificate was signed by L." ..,,:....... � : .JL.L f .. M.D.
Address � 3.. ;35 c-4. .¢_,f.., :� ' :<. 1.1,6C .C. )7 Y
Place of Burial (or emoval ../. a 1 0 . `-cam 4. ,--(.>--‘---' ... �/
(If body is to be t� r rily held, fill- n�pa cc'la
Cemeteryi �^ l 4 -z..e Date of Burial J F 19/-
(If body is to be temporarilyf�helyd, fill in space ater)
The CERTIFICATE OF DEATH containing the above stated particulars, h ving been presented to me, after careful examination,the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have ecorded it in my Local Record with the a ove stated Registered Number, and on the basis thereof I HEREBY GRANT A
I _
to PERM.....�/fit.-�7 '�-�..�(%�t# -
-3 �
the .. .. .. .. <2 - -r'°`-��-'' to hold temporarily and :. .. the b y
n ertaker or p son h vip harge of cor se) ( , remove or of s ose-of (state how))
Dated .. 19 ........3 (Signed) `!
tr r
This Permit is suffic ent for the Removal (and Interment or Cremation)of a body to y part of the State(subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Perm t(VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of '' `' was / - 19_
(Interment or E-rerno.4+ 4
(Name of Cemetery, Cr aruum rrc.)
y %
Section Lc /'✓ Lot No. / 7 " Grave No.
/ (/ ,
Si ed , ,:,.
(Person in Charge)
Address
ci,�< ( 7
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date o
person is in charge, the FUNERAL DIRECTOR or UN
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Regir
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERT S'
violating the law relative to the return of permits are liab o
a penalty of NOT LESS THAN FIVE DOLLARS NOR M E
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.