Gaffney, Clyde NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
_1
/j/j n` Town, Ville j Registered No.
Dist. No; _.0 / Co y `a or City �/j cz-
-' i`L- (If city, e street address)
Name of"deceased.. -'Z e_- Veteran
(If veteran, give name of War)
' Single, married, i wed, 4
Sex r2._._.... or divorced (write the word ' - - ate of D t / L' - . 19.
Age j Years Months Days .. Birthplace ;�z s c
Cause Death !¢ '.. ' ..
Certificate was sign�d by .. M.D.
Address &I I L ,. ,. - . f4t-e -- -1-1-"e ...
Place of Burial,(or Removal) _ _ Ct/
(If body is tcle_re.phporarily held, fill in space later)
Cemeter -a;-_.`— - Q- -z-z .. Date of Burial /21 A -- - 19-.
(If body is to be temporarily held, fill In space later)
The Certificate of Death containing the above stated p ticulars, having been presented to me, after careful exami-
nation,,the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have, cepted the same for registration, have rec ded it in my Local Record with the above stated Re i tered
Nu r,Jand on the -basis thereof I 4IEREBY GR T A PER ]� �')
(N (Ad ,
�°1-/yu-c` i� .�- - re4oraril and the body
the _ .... _-• --._
(Undertaker or person havingcharge of co se) •�{ ter,remov , •others. spore a t e howl' ,,�
Dated / __ , 19 z (Signed) I' �/.�.�..la � _-sf.�
Local Registrar
This Permit is sufficient for the Removal(and Interment or Cremation) of a body to any part of the State (subject o 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 of wad ' 18_
(Interment or Cremation)
(
-- (Name of Cemet , Crematorium, etc.)
Section__— -'`— 7 Lot No( -%�? Grave NO
•
(Signed) -—�ef t
(Person in Charge)
� r
1l �c •
Address
Person in charge must return this Permit to the lelistrar
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.