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Lynch, Florence NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT I« 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 CERTI- FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �� — R gistered No.w G Town, Village > 6 Dist. No.`��©7 C unty or City (14 If city, give street address) Name of deceased-___- ---- --- -- - ---- -CR_-_ - - e Veteran • • (If veteran give name of War) Single, married,widowed, Sex —? or divorced (write the word) _ 21r`-/-1 - Date f f Death -4__SW 19__77- - Age 710 Years -_- Months jays Birthplace ` Cause of Death l� _ 'me_ Certificate was signed b �G� �/ ` _____G_,._. M.D. Address 1 7 .64,t.k_---e Place of Burial or Remov 1) --- -t'�� Q�itr�o (If body is to bet orarily he d fill in spac later) Cemetery Date of Burial f 4 19__72 (If body is to be temporarily held,dfill 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 ccepted the same for r gis . ion, have recorded it in my Local R ord with the above stated Registered Number, and on the b thereof 1H RE- BY RA A ENRMIT / 'L,%G 4 ,, ,./.-- ame) Address) the "C _______ _ �'L to hold temporarily and the body (Unlertaker or erson having charge of corpse) (Inter, remove, or .therw' e dispo-1 of s to how)) Dated f 19.._7.�' (Signed) This Permit is sufficient for the Removal (and Interment or Cremation) of a body • ,' part of the St e (subject to local cemetery or other regulations),unless removal is by common carrier, in which case a Tra Permit (VS No. 62) is required. FORM VS.61.(REV.6/63)(7A2-53) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE k . Date of 6was 4'1L `- 19 /6( (Interment or Crematio' (Name of Cemetery, Cremat.,4 etr.)- Lt Section Lot No. -' Grave No. (Signed) ti' • (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 UNDERTAKER MUST SIGN ABOVE STATEMENT, write across the face of the Permit the words "No person in charge," and FILE PERMIT WITHIN THREE (3) DAY with the Registrar of District in which cemetery is locate SEXTONS, FUNERAL DIRECTORS and UNDER- TAKERS violating the law relative to the return of permits are liable to a penalty of NOT LESS THAN FIVE D LARS NOR MORE THAN FIFTY DOLLARS FOR T FIRST OFFENSE. The law will be enforced. Local Re trars are required, under penalty, to report violations thereof.