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Pederson, Buddy Iona VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tr 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 DURABLE BLACK INK. --Town--- Registered No.—..1__Y.._V....._ air;lldgc Dist. Nth.6.4/.4.County...lei..� --i..f or City ���� (If eit' give street addre71\1 Name of deceased . . . Veteran /� I Sin marri :�'!d. ' ed (If veteran. give name of War) Sex Color t) or ivorced (write ,e word) ' vt-4a?Date of D a y 95, Age �0 rs .Months .........Days Bi place � . .��G'� �: .�. Cause of Death ... .. .... �... Certificate was signed b ...... .... M.D. Address...,.3../.... Place of Burial for Removal) :r�z - 747 (If body is to bet arily Id in sp a later) ._ a Cemetery.:- - Date of Burial o`,/"" . ..`' 19'-- (If body is to be temporarily hel , I in space later) The Certificate of Death ontaining the above stated particulars, having been presented to 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 yistered Nu the basis thereof ERE GRANT A PERMIT : moo'. ( .d to ) '`sf C - r q ..r.-— .. ' ...........i /.... the �-7^ ..d to hold temporarily nd `y. - '_. LL.'.�aa) the ody. (undertaker:Toon having charge of rpse) • (Inte rem • orat5'eivci dls,ose of(state howl) Dated..czs/— / 19.. .. (Signed). C/.�.... .... . .... - Local Registrar This Permit is sufficient for the Removal (and Interment or Cremati of a body to any part of the State (subject to local cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required. ENDORSEMM OF SEXIDN OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of (, / / was '1:6--v-w.2-,., 19 (In*irmeenntt'or Cremation) (ha of Cemetery, Crematorium, eto.) Section Lot No. Grave No. (Signed) (illJQ (Person in charge) Address vr• 0 . ': G c - /.: ., 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 SION ABOVE STATE- MT, 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 re- quired, under penalty, to report violations thereof.