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Alden, William NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT igr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town, Vilrage, 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. Town, Village Registered N `. ./3 3 Dist. No. 2.S�/ County or City cif lc (If city give st et addres Name of deceased W kL-L i 4v�n ei. �.QE,Ni Veteran des . L • 4AJ (If veteran, give name of War) Single, married, widowed, rp (�� �7 Sex VY'4 2 I . or divorced (write the word) Parr 1 -d Date of Death 3uN� _`I 197 7-- Age 5.2' Years Months Days Birthplace n eA.A.) y©f t ') Cause of Death .P RO o r4 i U. QCCL-L) StOtom) Certificate was signed by AC-(e- P1s T aQ M.D. Address..6P A100A C Ot.) z k- S P ATO,� �Q.0..114.c S Place of Burial (or Removal (3 L�-1.JS FALLS t NCeC ) Q'CiC> (If body is to 139,temporar y held,‘ i l in space later) Cemetery (. .L 1-�O.rt " .5 Crf'.1A1. . Date of Burial NJU,0C.-- (2 19 7 7 / (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 registra- tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A PERMIT r ` p Q,/' /� n [�,� to �.ak.n �J.., 0 ' t l_� ..L."T....,;�. C-A.-1o6 tT 'kv c-- 5• �7 Lis u (Name) (Ad ss5 the UP 0 .i.tNi<fir to hold temporarily and \ .�.' (.(N.4.e... the body (Under ker or person having charge of corpse) ir' "' Dated ��1a‘{ (� remove, r therwise isp a of_(state how)) . .1.0 19 .7� (Signed) . r Loca R tgtrar This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the tate (subject t 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) (A2-248) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of nt was �/ZU'r ,,C 19 7 (Interment or Cre ation) (Name of Cemetery, Crematorium, etc.) (7 Section " Lot No. : Grave No. (Signed) (P rson in Charge) Address �'� f � f. " , LL U. Y 1 ' Person in charge must return this Permit to the Registrar of his District within SEVEN (1) 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.