Gifford Jr., James term vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt This Permit eau 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 CERTI ICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Rerci No .. .. .-—.
r , ' Village
Dist. No'3-6 C ( County..._.!`•' C or City ``•...
(If c^ty, give street address)/4
Name of deceased.... .lj/.,....... Veteran
Single, married, wid (If veteran. give name of War)
Sex �\ Color or divorced (write the word)... Date of D th 1Q �'3
Age Years Months ,1.........D s Birthplace.....f f G �� /J1•�
Cause of Death-...5rt`........
Certificate was signe b .. . .. M.D.
Address •
Place of Burial (or Removal) •. ':'V.�.... ..
C;) -i-A--e-P--"-Z--G-'t"/'"%(If body is to be teipi arily h ,Ill in spa later) /7 fin 1
Cemetery `tx-tom` c `1r'� Date of Burial /(�(�)� Z
(If body is to be temporarily held,fill 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 have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numb , and on the br er f HEREBY GRANT A PERMIT '3 — `l
tr
to '.h..4�r:d. h -•411 ( a Address)
the ('Lh to hold temporarily d the body.
(Urit,eer�ttaker or person having charge of corpse) (Inter,remove,o otherwise nose of(e is Low])
Dated '1 14 I.? / a.....19.2e...: (Signed)
Loc A
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any art of the State (ambient 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 PER KIN IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of9/^1/M-", -J1- xtwas341114/-
` 2' 19 `/2
(Interment or c iai‘u)
SUMUL
(Name of Ce tery, Crematoriuke, etc.)
4/,
Section Lot No. 2 Grave No.
(signed) L l.„,,,_ „7.: F'
(Per on in charge)
Address � er,t-e<9
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 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.