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Carroll, Robert NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tar 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. a > �, own, Village egistered No .22. ���Dist. No..� . County .or City - !-L� (If city, give street address) Name of deceased Xakci- Veteran ..i.t.-- .i,/ (If veteran,grre-rta rt of War) Single, married, widowed, '//// / y Sex or divorced (write the word) ..... .Date of Death `6 19/ Age -r Years Months Days Birthpl e '. . `-' Cause of Death - : ° /AilL' � Certificate was signed by ...a,..c� )7 .-4 M.D. Address U Ca `7 f� - Place of Burial (or Removal4 ( (If body is to be to o arily d; (i i space ate!) / Cemetery ... (...... .. ` Date of Burial 19 (If body is to a tern orarily a d, in space ater) The CERTIFICATE OF DEAT 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 ecorded it in my Loca Record with t e above stated Registered umber, nd on th asis the eof I HEREBY GRANT A PERMIT G /jam/, �. to .. ... ( fZ11--- k7 tea e) �.. .(tad••ess the r1., (rt-- to hold temporarily and 4, 9.. the body (Undertaker or person yin .charge of corpse) (Int emove, oth ise dispose of (state how)) Dated ,C 19 -7 (Signed) ,i,, s`t Loce.Regigtrar This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a part of ti-e 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. 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<it-it- was 1� 19�� (Interment or Crematio ) 2,11; (Name of Ceme ery, Crematorium, etc.) Section• knd i Lot No. of / Grave No. /r u� (Signed) Person in Charge) Address 35 /, 2j/L2, U 4 AV 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 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.