Gallow, Isabel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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. }<2s
Town,. Villag LIZ- Regystered No.
Dist. No. G'% County G or City �-e r
(If city, give street address)
Name of deceased Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex , , or divorced (write the word) Date of Death 77 19 . V.
Age ..5 • Years. .. Mpnths D s //���� Birthplace /
Cause of Death i'� /.e. •`^"...`2 ... -7
Certificate was signed by
Addres
Place of Burial (or Removal'
_Il..in �Ee later 7,,,,/„22--c-s-. 47
"
(If body is to be"temporarily e d fi `� )
Cemetery !� " '°.. " Date of Burial /..ef„3' 19 -/,'"
(If body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, fter careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have rec ed it in my Local Record with the above stated Registered Number, and on the asis thereof I HEREBY GRANT A
PERMIT ` 7 / 9
to /// c.e-�i.. �{ (Add-ess)(Nam
the _ to hold temporarily and y„ the body
(Undertaker or rs n having charge of corpse) R (Inter, re ve, or othe Ise dispose ofYste how))
Dated "a— 19 ....�... .... (Signed) • �.
c
This Permit s sufficient for the Removal ( d Interment or Cremation)of a body to any part of the ate bjec local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is re Ired
FORM VS. 61- (REV- 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
fij
Date of ��f'� ' was V2-`'1/319
(Interment or C*eats4ie.$)
(Name of Cemetery, C at t tina �,,,�
Section Lot No. Grave No.
'Zale
(Signed) L—
(Person in Charge)
Address R'irie �''' `C..
A 4- E .,Q+—,, —. - ,, :3; .
Person in charge must return this Permit to the Regi ± ,
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 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.