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Scoville, Doris 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. 7? Town, Village Re stered No. Dist. No..5. Q I County A..1.ofr 6-n or City (Lai ta1.I.� pp (If city, give street address) Name of deceased ....\ R U..1.5 „ e.C.L l 1( Veteran no • (If veteran, give name of War) Single, married, widowed, Sex F n1.a 1e- or divorced (write the word) ..:S.i.n�..l. Date of Death .../a .. 19 'iS... Age ((t Years Months Days `..?�� \ Birthplace t�,l.y • Cause of Death ACi lic . h'l Li.....�,.: r.... .(.,v:L..014( A J��.t��lS K(..4.,,,- Certificate was signed by r IC M.D. Address Z .e.f� 0l'' - .E..:{1,/J..... Place of Burial (or Removal) . ,lA fl.s DIA / (If body is to a tempoqrra�rrily h d,•(i in space later} J Cemetery ....�1-(�....._V..I.�.LO Date of Burial ‘ ' 5 19..75 (If body is to he 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 (Name) )01 ress) the (.fl. el.7 r, to hold temporarily and ie4.:11‘ r the body (Undertaker or erso having charge of c r se) (Inter, e, or wi; o state how)) Dated t- 19 .. 10 (Signed) ocal egisttr'ai This Permit is sufficient for the Removal (and Interment or Cremation)of a body to anyf 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. FORM VS. 61. (RRV. 6/63) (A2-248) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of ZGGff f-/-2-t 19 7�.-- (Interment or C :1'(:)--7 ' / ,--, . (Name of Ce etery, C Section �7 Lot No. 1-7'": rave No., (Sld) -1i'1 j p61/4"----c-r---7 -r----7 (Person in Charge) Address © -. / 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 acro e face of the Permit the words "No person in charge, d FILE PERMIT WITHIN THREE (3) DAYS with the Regis of District in which cemetery is located. SEXTONS, FUNERAL DIRECTORS and UNDERTA violating the law relative to the return of permits are liabl o a penalty of NOT LESS THAN FIVE DOLLARS NOR THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. law will be enforced. Local Registrars are required, and r penalty, to report violations thereof.