Gardner, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vitt-age, 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. �� ,,��
egis d ic.‘Dist. No. `��U/ County (t Town, Villa e1� "''''or City g (If city, give street addre _
/'/
Name of deceased dIR4.-. Veteran . Ggiv am .
(If eteran, give name of War)
in le, married, widowed, (s3
�ySex or divorced (write the word) . Date of Death ... 19 •.. ..
Age .Q - Years Mo the Days Birthplace
.7 Cause of Death .. .... •'
Certificate was signed by.... ... ... .... "C.
... ... .. M.D.
Address ... .A..... .. .... .. �� > `� �•.
Place of Buria (or Removal ....
(If body is to porarily ie ,•( � space r
Cemetery Date of Burial /ll 19 7r.
(If body is to a temporarily held, f to space late
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to , after careful examination, the
same appe ring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ha a ecorded it in m ocal Record wit the above state Re
to Ctit ( g d Number on th asis thereof HEREB GRANT A
istere
PERM
...
ame (Aadress)
the .... ... -11
to hold temporarily and .. the body
(ilndert et or person Ii charge of c r,t e) (Into move, or otherwise dispose of (state how))
Dated 19 ..7. (Signed) Aal
This Pe it is sufficient for the Removal (and Interment or Cremation)of a body to a partthe Statect to local cemetery or
other regu ations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
F'OItM VS. 61. (RMV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of(y 11/L-17.t•rr/' was ,/c19 7.f(Interment or Cremat92t (d
)
(Name of Cemetery, .Gre+aaw ium, etch
Section Lot No. Grave No.
(Si gne 1---i iLr,tit
(Person in Charge)
Address
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 UN9E -
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge," a
FILE PERMIT WITHIN THREE (3) DAYS with the RegisRegisie
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
violating the law relative to the return of permits are liable
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.