Rowell, Gertrude NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
mom' 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 COMP % CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Regi er d No.
Town, Village
Dist. No. L-5Z0 County t1/4A (-Zit/ or City .Q.. > -c)
�` - If city, give street address)
Name of deceased Veteran
(If veteran, ye name of War)
/�- Single, married,widowed, ��
Sex or divorced (write the word) t-e_...st, Date of each 3O 19.7
Age 2 Years -___ Months _ Days Birthplace
Cause of Death C •
- - -- -- - - - - -Certificate was signed b �'%1.1-t_..E.� - �`-- M.D.
Address 16 --rif . ,to_x-. 1L Ay
Place of Burial or Removal ._ .. -- }L�--2-�-0 L_<�2�
(If body is to be to orarily held, I in spa e later) �1- "
Cemetery __ YYY Date of Burial 19__7
(If body is to be poeld, fill in space later)
The CERTIF ATE 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 registr o have record0 it 'n my Local Record w th the above stated Registered Number, and o the bas' thereof I_ ERE-
BY GRA P IT
to - 1 _..4 ��� k
1 (Add ess)
theto hold temporarily and ___ the body
(Unlertaker or....t}=,
having charge of corpse) (Inter, ovegqr othj ise ` pose of (state how))
ated 19 (Signed) ' 1. _Local Reg/.trar —1,-,--,-21This Permit ient for the Removal (and Interment or Cremation) of a body to any pa of the tate (subject to local
tery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. ) is required.
61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON I \
gli
CHARGE OF PREMISES ON WHICH INTERMEN cep'
OR CREMATIONS ARE MADE co"�JS
Date of 'e1" was r J / 19 7P
(Interment or Oft,TMari^^i
(Name of Cemetery
t!P--'e ,6 --r //�
Section �- Lot No. .._ �' ,L Grave No.
(Signed) ,.Yl I c_'i"w`-/
(Person in Charge)
Address
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 relative 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.