Gwinup, John NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ilgF 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
T Vi1 C
ze
o., Cit Registered No
Dist. Nf1 ..� .0 .. County j y (If city, giv ree ddress)
Name of deceased..1, C2 ...Z ... . ... .. ,. Vetera "�-`
(If vetergw give name of War)
Single, married, widow , ,/
Sex or divorced (write the word) ,!/� Date of _ h 4/ . 19�6
Age ,, �_.- ..Years. Months Days Bi place .
Cause of-Death -t'c'
Certificate was signed by ���... 2 .D.
Address - ,..,,
N
Place of Burial (or Removal) ,
(if body is to be temporarily held, fill in space later)
Cemetery ..��-e. Yam " . Dat f Burial 3// 19
or body is tO be temporarily held, fill in 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 cord with the above stated Registered
Number„Sid on
the basin thereof I HERBY GRANT A PERMIT
"7--,---
(Name) ll,<' (Address)
the 1," / to hold temporarily and the body
(Undertilw 9r person having chargetmf core e) /�Ju (Inter,remou other ea di of (sta how]) /\�
Dated. 'G t e i z. 7 19 ..' " (Signed) L
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj ct to local
cemetery or_other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 62) is required.
Form VS. 61. (Rev. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS QR
CREMATIONS ARE MADE
Date ofY'!h 7 was%///_L/Z�/L 19 a
(Interment or Cremation)
G ---- fie , :. � �
(Name of Cemetery, Crematorium, etc.) -- /
Section_—._ -5_ " .- . Lot No. / 7 V Grave Nos
7
(Signed) _ ../E 2, IL'L
v- J Ce.7,2_,(,�(
C (Person in Charge)
Y-'..L--
Address ," r''�K�r y
,,i� � / z
Person in charge must return this Permit the Registrar
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict 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 required, under penalty,
to report violations thereof.