Gonnyea, Arthur NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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. 7
/ j , ) Town, Vill 1R ste....4 No. U
Dist. No. 5�U C nt (s�(,l or City ...
////����,, (If city, gives eet addfess)
Name of deceased /771" Veteran o)
(If veteran, give name of War)
Single, married, widowed, ) /
Sex .: � { � or divorced (write the word) al Date of Death .... . -�4( 19 ..25:..
Age . Years .. ..a .Months Days Birthplace
Cause of Death �� ..
•
Certificate was signed by .... 2 / ' . M.D.
Address .3 �l/`4 .Y..to l '�
Place of Burp 1 (or Re oval
(If body is to a tempo i h d, I II in space pi.)
Cemetery .. .,Q�-,.-.f - Date of Burial ... _� 19� r
(If body i, o e tem orari held, fil 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, recorded it i Local Record the above stated Regist d Number, an n the basis thereof I HEREBY GRANT A
PER IT
,
ame / / (Clara .7
the to hold temporarily and the body
(Undertak or pe n laving charge of corpse) (Inter, t 4•ve, or rwts spostate how))
Dated — 19 .,2� (Signed) ,.. .
/ Locz;„Regigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any p.rt of ti.e 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.
F'O tM 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 Qthr-Ptiiwas___ Cd` 19 75
(Interment or Cremation)4/.
< rr ,
(Name of Ce ett�i e�rematorium etc.)
Section POL_C Lot No. / 7 Grave No.,q
(Signed).
( erson in Charge)
Address 35 ��rD , 41, /V2-it,.),2 ' l/
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 t'o
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. 1.4
law will be enforced. Local Registrars are required, uncle)
penalty, to report violations thereof.