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Yager, Deborah Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT to This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town, Pillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF )EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No.__.._...._....._..... , ©© �Q Village )ist. No..., .. ...J..County..._.....C��,�4/!.................. .. or City , (It city, give a t address) eteran Jame of deceased .. ...¢ �2.:. . �-� ,,,� /' ) Single, married, widowed, (If veteran, give name of war) / >ex Color..lN or divorced (wnte the word . .. ... ate of Death 0 .. ... /' .19. .., I , a y.it, , 1 ,�p� age Y rs -Months 6.... .Days ) Birthplace. ' /... ... ... • -1!"J :ause of Death...... .... P``g / �...!i... ... :ertificate was sign d b M.D. Address f ' 'lace of Burial (or emoval) 1 '"I' ' �' ' If body 1s to b mporarl]y held,fill in space later) r :emetery V..e e .`'(,1..... ,_;,...�.t _ 6 -- . . .Date of Burial . . .. 1 19.. .� If body is to be temporarily held,fill in space later) Cho Certificate of Death containing the above stated particula' , having been presented to me, a er careful exami- iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, have accepted the same for registration, have recorded it in my Local Record with the above stated Registered V , and n e asis thereof HEREBY GRANT A PERMIT o.. '*'. 1--`4......, ( dress) he.. .. .r.... to hold temporarily and tr: body. (tinder r or rao havl g charge of coulee) ( r, re otherwise moose of[stAte bow] 4 )ated ...1. ...19.(&�.. (Signed) C:i Local Registrar This Pe t is suffi tent for the Removal (and Interment or Cremation) of a body to any part of State (eubj 0 to 111 emetery or other regulations), unless removal is by common currier, in which case a Transit Permit (VS No. 62) is required. ENDORSEMENT OF SEX'lUN OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE . _ Date 721-1:e i.e_4.-r was 19 6 Z-.'" (Interment or Cr tion),r / �y r.- zi.-; ,l t` m (4:7::=-Zir (Name of Cemetery, Crematorium, etc.) ..- G5i4e-e.--, ...,/'E4;Lt,„___". Section Lot No. Grave No/ Q z2-- (Signedf/i= 4-_ ,� t / 1�,,,lig.� ;// .4,44 (Person In charge Address 0..-e/ e4241"2.„;., .... . _47,A.: Person in charge oust return this Permit tci 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.