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Williams, Lila Form VS.AIL NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT or 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 DVRABLE BLACK INK Town Regi ered No._ �< • Village .�e/2 p p Dist. No.:`�.i.Li1...kCounty... ." or ity /� (If eity, give street ad� ") Name of deceased. ?-4... .. :C.,4.rL.4,,•. --(.44,4/ASd) Veteran Single, married, widowed, c tf eras, give name of Wax) Sex f1 4,...Colo . .. . . r divorced (write the word). ...... .. . . .. ...Date of eath.. ..:. . .f' 19.ee. Age....5.? Years 6. Months / .dr»~ .Day f Birthplace. . . ... 4 . . .. .• Cause of Death 2 .. %...bffi .,.:, ,.. �� Certificate was signed by s7 M.D. Address . :alas ..,. Place of Burial (or Removal w n--kz,- � � . , .�..... (If body 1s to b}�o;arily held, in space lat Cemetery l,.t"..vCru..1t t......7 ..rGti.... , S!� Date of Burial / 19 v (If body is to be temporarily held,ell in space later) The Certificate of Death containing the above stated particulars, having been presented o me, after careful exami- nation, 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 Nu and on lithee� bba/sis th ,f)II Y GRANT A PERMI aJ ' J .7-4:z...44.4.., 4.. (-/ ' (Na ) (Add a) the... .L,. .. ....�.. ..' to hold temporarily an . ... the body. rtaker or person having charge of corpse) Inter,remov or rwise disoo of Isla,how)) Dated.. ... $7 19J:,G.. (Signed) . ... .. >< . •�L1G4,. j, 'Local Registrar /, This Fermi is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (trabjeet to local cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. • ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS • ARE MADE 1',„ ) ,c t :_ . Date of 'Z- 1� -J���_ ,,,�I was C 1'l /ir (Interment dr Cremation)] / (Name of Cemetery, Crematorium, etc., Section Lot No. >4V Grave No.L3 • �L. �Scc vL�(:.. • (Signed) te— (person in charge) Address l G Person in charge Heist 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 STATE- MENT, 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 FIFI'Y DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Registrars are re— quired, under penalty, to report violations thereof.