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Marks, Henery Form O&eL NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT sr 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 R gistered No. Vill ge Dist. NCI..:1.ta ...l County...Z../444.e-- ,-) or City -- :©G---Ce o .... .. fir..J. _... (If city, give street 'ddre6s) • Nam of deceased., .:.. rt� � ...2 ' Veteran /�� �,S ingl arned, widowed, / 6 (If vet n. give name of War) Sex' .. lt,4.Color. �. ... or divorced (wnte the word).?�G g.4l....Date of eath. ° t. .194,4 . Age .4.5.J Years... oaths Days Birthplace. //441 / Cause of Death....,,,.-a- .��c.:f�az..±-• . Certificate was sig;ied by. .. .4.1f.. . 4' M.D. Address... I • . . y., y., Place of Burial or Removal)...,.....:.. ..d. -� . (If body is to be to porarily held ace later) Cemetery,....- �� max., ate of Burial, 471 19.�./. (If body is to be temporarily held,fill space later) The Certificate of Death containing the above stated particulars, having been presented to me atter 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 Nuns , on basis th f I HEREBY GRANT A PERMIT to . . -I ‘7,717.......-. ..K.4:4-a."1-7,1erle.- rOrle C-. ., -?,--a'Y .)7 'it- _,,,,.th ��2/ ) to hold temporarily and C41.1trse) the body. Dated(IIa rtaker or person having charge of corpse) (Inter,remove,or o dispose rwlse of[state bow]) 19.. /. (Signed) Local Registrar This ermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sr..bject t ,oval cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requ' . i • ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of l '+ ""U1 was '`Tn r)i c` 19 f./ (Interment or Cremation) Lt ,y7/�� (Name of Ctery Crematorium, etc.) Section Lot No. Grave No. (Signed) terl"W.e_ lt (Persop in charge) Address 7 C) 14N 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 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 df District in! which cemetery is located. i 4 ; 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, rfo report violatiol:r thereof.