Galusha, Harry Tvrm VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
is 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 CERTIFI ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town egistered No.__ ,.
Vittage
Dist. No.. County. Li.)..a.1.-AC.)—Q... .. z.... ..
(If city, give str adds )
•
Veteran � ,...0
Name of deceased ... ... ... ..... ..,�. .... . . ...... ... : ..�.
rISingle, tied, widowed, �++'�A C If veteran. give name of War)
Sex,.T•t . '•.Color. .. or divorced (write the word).. .Date ath �•f 19 •2—
A ..*..40. .1... s the D Birthplace. •
ti� l
Cause Death.. . {.�.� .�;.V
.SZSL M.D
Certificate was e ' b
Address � `L. ,1...c.:..r.. . ••
Place of Burei,l--(.Qr Removal) TM �-'^-1 CT' •• `
(If body is to b temp rarlly held,ill i space later) 6 19..
Cemetery -^"--C- ..,i.Sl..4.4A.a Date of Burial { • ®
(If body is to be temporarily held,fill n 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 SATISFACTORY AS REQUIRED BY LAW,
I accepted the same fo registratio , have recorded it in my Loca ,Record with the above stated Registered
um on the b S' t ereof I H REBY GRANT A PERMIT i', (, �
reT tom... . ......... .
(, ame) rem)
the to hold temporari a d he body.
(Uri rta er or person having charge of corpse) (Inter,remove, e ee df,Dose of[state ho j
Dated ,1.. ) 19. j..2._ (Signed) .
al It
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any past of the State (+abject to local
cemetery or other regulations),unless removal le by common carrier,in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date oC ';Z';" was // 19
(Interment
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No./7
(Signed)
(Person in charge
Address �, C
Person in ge must re his Pe to �i/
the Registrar of his District within SEVEN (7) DAYS
fran 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 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 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.