Hewitt, Goldie -,z vs.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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 CERTIFIC, - OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.._..
� Viirrgge
Dist. No. }6 County.. ala1191N.- orLity-
(If city, e street a tees)
Name of deceased Go.L ',.. •• • .( 1.� Veteran ngle, married, widowed, veteran. give name of War)„.
Sex.. divorced (wnte the word) Date of Death.... 19 •�?
Age �`� rs.� o s .....Days
.. . . ... .. .... ... .e; _
Cause o eath ��,.1't.� , . . .. .... .. .
Certificate was signe y. ..4.... "Q... . .1 M.D.
Address �. ..C5 *1 Ctldl —.--i2"
Place of Burial (or Removal)... .. . ... .... . . .
•
(If body Is to be ter,' artiy held,fill I Dace later)
Cemetery c. Date of Burial i ZT 1963
(If body is to be tern arily held,dll in space later)
The Certificate o eath containing the a ove 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 hove stated Registered
N , o the-has' ereof I HER Y G A PERMIT rj
11.6i � �
l ? V-- `' (cadre..)
the..,..,•• , .. .... )
v to hold temporaril tip ., t body.
(Unde ker or af acing ebarg of corpse) (Inter,remove,o vv'e se lsnose of [state Low)
Dated I pp r/ 19.�i 3 (Signed)
. . ... ..... . .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to 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
Da was 19
�/ (In anent or )
, ._
41„ ,,. Gam,s, '-�j
ame of Cemetery, Crematorium, etc.)
Sect S- Lot No..1 crave No. ____
(Signed) �j;a.-/ .--- A5///'- '- 1
(Person in charge) �'
Address /•X 61/ ( ?<,�• „..-.1 .4--c--'--. /1404,
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 OFrENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.