Gourley, Sidney Form oa sI_ NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zir This Permit an 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.—..,7.P
Village ,,
Dist. No.. .?�.f(t...County..... . ....[ — or City ./..;/ ; ...1. :/
�p�, � (If city, give street address)
Name of deceased ���'" �`."..d:�'l'*. f.,,7 Veteran -k`CJ
lei Single.);rdarried, widowed, (If veteran. give name of War)
Sex - Color..1 or divorced (write the word) hi ... Date of Death c4D/4r.. 19.E....,
Age 7.3 .Years.. Months Days . Birthplace Je.. 4-g..
Cause of Death � "-......sf::G ..
Certificate was signed by _ -rea.r,.�¢- M.M.D.
Address tee... z.r ,F ,.,,, �"
Place of Burial��Removal) S �i7�'t f �/ •�• 2 6
(If body is to be to ly held,fit injpace later)
Cemetery ..... .�.2...,r /„ ,�-( Date of Burial c1 19........
(Jr body ie 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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, anon the basis thereof I HEREBY GRANT A PERMIT
to N' r , , 64,........
'Mame) (Address)
the :':-or.—....>!. ,:�-.............to hold temporarily d�L- r.,?.,d..�" the body.
(Undertaker or19of corpse) ` r,m iy, r o se dispose of [state bow])
person having charge (Inter, mo��
Dated / (Signed;a..... r
7 Loc Itegirtrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eabject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSFMFNT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREATIONS
ARE MADE
Date of 21 ,►,-- was 19 6
(Interment or Cr tion
1,,,
/,<.:
( ame of Cemetery, Crematorium, e'tc.)
Section ,� Lot No. Grave No.
/.
(Signed) , Cam„.X.--('
`_,i, - iSC L �-� C
(Person in charge)
Address �7-L`C. 2 •.,''kC�'c'v"--
,--4 -
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 cords
"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.