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William, William NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT rir 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, Village ........... Reg.. i re N Dist. No. ©f County !NetA/Le ---- or City ........ //,� � (If city, give street res.).. . Name of deceased tX/�'� •„1.i(--Q,-�/` Veteran ...... ��-, (If vet an, give name of War) Single, married, widowed, ,. ,Sex . ....- .. .or divorced (write the word) . Date of Death .... 19 7‘,.. . Age Cr Years Mont+ .........Days Bi place .. Cause of Death , -+ .'.. —' Certificate was signed by ..... �,.. y M.D. Address �1/°j, ��- `rX7 Place of Burial •r Remova► .. .. (If body is to be �torar.t. he, Al s•ace ater Cemetery _.... .. . Date of Burial 19 7C • (If body is to b emporan y e ., II'in space ater) The CERTIFI _ATE OF DEA H containing the above stated particulars, having been presented to me, afte areful examination, the same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY AW, I have accepted the same for registra- tion, have reco ed it in my Local Rec d with the above sated Registered Number, d on the basis there f I HER Y GRANT A PERMIT • IL to t• �f�. me ..... .. <'!. ... . .. if>.... {A are 4. WI 1 h st/ �/L the ,Ey 6. to hold temporarily and , r rite ody (Under ' of or person having charge co e) Cr, remove, or otherwise dispose of (state how)) Dated •. . / 1 . (Signed) A• L This Permit is Tfficient for the Removal (and Interment or Cremation)of a body 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. 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 / / was 19 7 l (Interment or Cremation) ame of Cemetery, Crematorium, etc.) Section 444 2, Lot No. /7 Grave No.,. — Si ed CC `�` �QA. (Signed) , (P rson in Charge) Address �,J ✓ LZc'LY/ ,.L-2-. V 2 y2_ 54 ,7 -Cj Person in charge must return this Permit to the Registrar of his District within SEVEN (7) DAYS from above date. o person is in charge, the FUNERAL DIRECTOR or UNDE r TAKER MUST SIGN ABOVE STATEMENT, write across face of the Permit the words "No person in charge," kg FILE PERMIT WITHIN THREE (3) DAYS with the Registrar of District in which cemetery is located. 4 SEXTONS, FUNE RAL DIRECTORS and UNDERTAKE 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.