Glasston, Merle 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. /�C/
Town, Village `/ Registered No. 4 Y
Dist. No....5 v..: ? County l..:C'GL..Y..r..F.,r:a or City // !��` 4..C.-% i t.e•t
(If city, give street address)
CI
Name of deceased `��..c 1 -I• " L•c 4.5-c...�......................Veteran yz'S -- .1(6Y..ek.....Cxt 1+...i:F..1—
(If veteran, give name of War)
Single, married, widowed,
Sex Yf Gt.Z . or divorced (write the word) )1().4..xx., a r( Date of Death .1.. - 3 - 19 .:7..5.-.
Age V6 Years .Months Days Birthplace 'f r'y 0,3.1""
Cause of Death C.a.c.d . Q c. 1 r P s i—
Certificate was signed by tY.!:'`..a'..:'4. n1.c r r.4 - f PI+ V M.D.
Address C-, 1_,.. ..f.1.A sf a.(..,.1. is , --' a/-
Place of Burial (or Removal) ...'pc-3 n u Cr LAt e.,�.t.yJ..a.,,...
(If body is to temporily hear d, fiil in space ter •
t .Date of Burial /R- -"— 19 7 S7
(If body is to he temporarily 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, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to -Fa r''t< S S Pa. -e ../3...6. 5�-a..r.k..e.n.....s.....•. F.L.e,.,......�L.4�.,5,�``� -
{ (Name) •�' ��r (A ress} the body
�� r U - to hold temporarily and „P
(Undertaker or person having charge of corpse) ( ter, remove, or other i e dispo of •te. ow))
Dated /c- 2
'i- 19 . .5
(Signed) -0�:�... �.....• ...,
Local Reg'
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local c etery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
FORM VS. 61. (RFV. 6/63) (A2-248) •