Gifford, Alan Form V&IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit ran 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. 1_
• Village Cc.c C. . if�
Dist. No . ..County...` L or City q'—,
(If city, give strews)
Name of deceased �..- ....d r. .. ..G.. G! Veteran JJJJJJ 111111` a .
= Sin le m fed widowed, r ((f v reran, ive name of War)
f ..� g r , ..� 19lv. .c
Sex.h.4,i.Lh....Color..Gl .. or divorced (write the word) -r'e to of pea 1
Age S- ears ..Months Days ; Birthplace,. eaer. . .. / /.:...
Cause of Deatb. ki. . . `-4:Ada. -4 �� - �
Certificate was signed by. ..G .C.� '°.Y..:.. ! eO.. M.D.
Address 4 ,� '-L,�... ... . .. .
Place of Burial (or Removal)... .. .. ( .C.-G—I-`/
(If body 1s tqq__b,_e,�tem,pporr�er�yaly held,fill In spacg er) / i
Cemetery..I .1... /.S6 .ci.c.-G�-�'r^..4r�,e,4< Date of Burial.. 3 19.ti..,
(If body is to be temporarily held,1311 in space later)
The Certificate of Death containing the above ' ated particulars, having been sented o me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the bast.1750,0REBY GRANT A PERMIT
/j 1 (eda a
they . e:fe :,�/,�..:� rs`?4,: ..�.c;.� to hold temporarily and .. .. . .., the body.
(Unde ker or person baying charge.of orpee) (Inter,remote,or snore of(state holyy)
Dated ',� 19. (Signed) 1 F.4 :t:rTz--t/
'sierra:
This Permit is sufficient for the Removal (and Interment or Cremation) of body o any part of the 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date7 '
, was 192
(Interment or Cr on)/
/;/—',"e7C
j
✓✓ (/ ( ame of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) ;7; , _��
e>1/
(Person in charge)
Address. �l r ��.-✓
Person in charge must return t s Permit to
the Registrar of his District within SEVEN (7) DA
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 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.