McGillway, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I« 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.
1v/ � � � Town, Village
Dist. No. County or Cijy
/,' I city, give street address)
Name of deceasedA U ( e• / "C- J.-eci Veteran
(If veteran, give name of War)
Single, married,widowed, , f
Sex .�C,--�4 C or divorced (write the word) 4A-cf. Date off eat17� /�l /O 19 77
Age -5.____ Years Months Days Birthplace &-,•• •
Cause of Death -s.- _ _ _Q-4. . -2
Certificate was signed by _,___ M.D.
Address 2 rn_- --- 7
Place of Burial r Removal -. _
(If body is to be to rarity held f 11 in space later)
Cemetery .L.--IN.12_ _?...Q„.4,,,1 Date of Burial /_ __r_2i 19. '
(If body is to be t mporarily 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 b Is thereof I HERE-
BY A P IT b / / SG �
t0 Y /f/
( ame (Address)
the I to hold temporarily and -1i the body
(Unlertaker or perso having charge of corpse) (Inter, re ove, or otherwise dis se f state how))
Dated /_ _.-/_./ 197._ • (Signed)
This Permit is s fficient for the Removal (and Interment or Cremation) of a bo any part of the tate (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a T sit 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 C� `-1'''tL' was /�` 19 -72
(Interment or o
(Name of Cemetery, Crematorium, etc.)
Section 62- "' Lot No. 78 L' Grave No.
(Signed) `L
(Person in Charge)
Address 0 j
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) DAY'
with the Registrar of District in which cemetery is locate
SEXTONS, FUNERAL DIRECTORS and UNDER
TAKERS violating the law relative to the return of per
are liable to a penalty of NOT LESS THAN FIVE DO
LARS NOR MORE THAN FIFTY DOLLARS FOR T
FIRST OFFENSE. The law will be enforced. Local Regis-1
trars are required, under penalty, to report violations thereof.;