Goering, Craig 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Viitage Registered No.
6..7 .County ff�..,.?x.,z. : L� of-City..Dist. No. ........V��. (If city ive street address)
Name of deceased .... Ci.��..-F":.. .... !L�.c..c..-.: Veteran
(If veteran, give name of War)
Single, married, wido ed,
Sex 1 or divorced (write`fre word)Wz..d_adz Date of De�th'2 .., ..G2.4g, .19 %a....
Age....( Years � I.M nths ,/1 Days Birt lace lt ��ke- ...
Cause of Death ..... ......... : .. Gt..:4.4i s.: .:.-..../...�5�.- .-::zle:V.-:21--rc-'� Y:C.-.:K.::4--�t.,.: ...
Certificate was signed Y k �p�' ............... . ... ... f/ c_, , M.D.
Address ..`:.--2-.Z t.,:s�®y�d -��- c�' C.A I 7
Place of Buria (or Removal ^Q- ..
(If body is to mporarily he , (i in space a r)
Cemetery c.-Zj �( Date of Burial -c2'3 — 19.4
(If body is to he temporarily held, i~ e later) �..
The CERTIFICATE OF DEATH containing the above stated pa culars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have r corded it in my Local Record with the above stated Registered N ber, and on the b is thereof I HEREBY GRANT A
(Name (Andre s
the to hold temporarily and t body
(Unde er or person having charge of corpse)) ,. (Inter, remove, r er tse dispose of (st ho ))
Dated ... ..c2.. 19 .Z21 (Signed) ,1:2/4,.1.t,,.c„ a..,as
ca Registrar ^�
This Permit is s fficient for the Removal (and Interment or Cremation)of a body to any rt of the State (subject to local etery
other regulations), unless removal is by common carrier, in which case a Transit Permit ( S No. 62) is required.
FORM VS. 61. (REV. 6/63) )3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of /LYrZ€?Lias 5r // U2c9 C�
(Interment
(Name of Cemetery, _.
Section Lot No. Grave No. /
(Signed) (L.
(Person in Charge)
Cam✓' '"'� _,,
Addres 66<1
Person in charge must return this Permit to Registrar
of his District within SEVEN (7) DAYS from abo a 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 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 required, under
penalty, to report violations thereof.