Goucher, Jerald NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
E ' 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.'�() / c�� Town, ,���Villa e'�y �Ze � �� L
Dist. No. County City CC
P-e-i--=W
f It city, give street address)
Name of deceasedVeteran
(If veteran, give name of War)
Single, married,widowed, o
Sex 2 " or divorced (write the word) of eath c`"" 1-7 19 7/
Age / Years Months .09--- Days Bi hplace 2_;&.,,,/,
Cause of Death 7e' 2
Certificate was signed by obi• M.D.
Address �^
Place of Burial (or Removal) n.. °i /-k)
(If body is to be temporarily held, fill in sp ce later)
'C19
emetery . '�• a_ 7 a.41 4 Date of Burial 19 76°
(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, after careful examination,
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 above stated Registered Number, and on the basis thereof I HERE-
BY GRAkV'I PERMIT rjn'�• ��-�A to
.✓/ 7 ` d"` • rjy'' ij 'n ` �r
(Name' / �,�� (r/�f
the _.OX-4 eoGG�w hold temporarily and t �' the body
(Unlertak r or pers n h wing charge qf corpse) {�Int ve, or otnerwi7-dispr ( ate ))
Dated -• 1 __ 19_.7/ (Signed) /rkl '� //
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ubject 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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of 'f "4e't-J was 4/ sCP— 19 7
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section1/6' 2 'K of No. Grave No.
(Signed) C�it-k,c�
(Person in Charge)
Address 3b J / llll0
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 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 UNDER-
TAKERS violating the law relive to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.