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Bills, Elsie Form vs.sL 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 Registered No._.__..._..... ._.....__ �' Village RAY BROOK STATE TUBEi CULOSIS HUSP41AL Dist. No County. ............. r or City QQ�� �... Trftitf,k'fb�'attegaddrees) Name of deceased Mrs, Elsie Bills Veteran (If veteran, give name of War) Single, married, widowed, Sex F Color '(`I or divorced (wnte the word) Widowed Date of Death J . 23 3_96349 Age .65 Years Months Days Birthplace...aR... Q.talagh.g2.,...a..X.. Cause of Death....uorg.e.stiye...hga .t...farlia.re...o mor...3..mQmth.$) Certificate was signed by N.o.rnan...ahe.fra.T7.,..1.i.D. M.D. Address .T ,y.. olcy.. .... Place of Burial (or Removal)... ,,.:-d..... 7./.' -. . .,. ‘.i — (If body Is tqgalte mporar ly held,till in space later) U Cemetery.l..f',--4. ...T7 Date of Burial.... 19 (If body is to be temporarily held,fill in apace later) The Certificate of Death containing the above stated particulars, having been pre'sented to me, after careful exami- nation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the a or registration, have recorded it in my Local Record with the abov s to i ered Number, and on thy/b a' HEREBY GRANT A PERMIT: r ' ./#71 ' (Name) (Address) th to hold temporarily 4nd I )he body. ndertaker or fir? having charge of corpse) (Inter,re e,'or otheresim dienoee of(state howl) Dated. '.n..Y3,:.,1,4.2' 19 (Signed) Local Registrar This Permit is sufficient for the Removal (and Interment or Cremation) 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. ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE 9- /-;/, " �... � 19 6Date � (Interment orwCre tion) % .._,-.)/ ' i ,� /,Z --e-'/z J (Naive of Cemetery, Crematorium, etc.) .C. -2,71ce___ed......oef—I . Section Lot No: Grave No. (Signed) //46?' . . , • (Parson in charge) Address Z'fit-/".).64_ \I/ r 7/.1., ' .!-(20°' _ 7z2Z-i7---, Person in.charge Heist - mis 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 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.