Gubity, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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, Villa °'
Dist. NoS� / County ( or City
(If cuy ive street ad ress)
Name of deceased 1 �Z Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex4,1Q-----"'
or divorced (write the word) 7/1a- Date of Dea / s 19 ...2.A e Y rs „Months- s Birthplace...t
Cause of Death ...(�(tjy1�.,�/ �9� ��-C. ,
Certificate was signed by M.D.
Address 4 .... Crevec„? J
Place of Burial emoval) / �c!!/,I e` It
(If body is to bet mp arily he , (ill in' ace a r
Cemetery %.-,1; �- �. Date of Burial .hJ— 2 19 '2
(If body is to he tem iorarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having 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, h. • recorded it ' y Local Record with the above stated Regi eyed Number, and on the basis thereof I HEREBY GRANT A
PER t
(Name) a�ressJ ‘.2
the to hold temporarily and the body
(Un er aker or pf son ing charge of corpse) ter, remove, otherwise dispose of (state how))
Dated /U 19 .... (Signed) L �je
• o ai`R !gibe
This Permit is sufficient for the Removal (and Interment or Cremation)of a body any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
FORM VS. 61. (RF,V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of ( ""7 L':"4/7‘‘.was /4/7 19
(Interment or msreoa#-
(Name of Cemetery, crematorium. etc.) .
-77// (, 1` z
Section / Lot No. Grave No.
/1-0
fir`
(Si 'gn 'rC
\J (Person in Charge)
Address 4-:"A) /
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. 'Tf
rlo
person is in charge, the FUNERAL DIRECTOR or UNDERt,.-
TAKER MUST SIGN ABOVE STATEMENT, write across thh'e
face of the Permit the words "No person in charge," �,yi
FILE PERMIT WITHIN THREE (3) DAYS with the Regist r
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
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 required, under
penalty, to report violations thereof.