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Guyette, Roger NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT Ili 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. Registered No. Dist. No. / 0 County ,, or City If city, street,ddress Name of deceased / O Veteran (�� (If veteran,give name of War) Ingle,married,widowed, Sex or divorced (write the word) lute of Death >hce.�.f, / 19.f Age ___ 6v Years Months __- Days Birthplace 72. / o�" Cause of tier_rni Certificate was signed by C. -11.__. M.D. Address • ,._ Place of Burial (or Removal) _._ ,.. .._. . (If body is to be temporarily h Id, fill in spa e late Cemetery __,_ _. __- _ Date of Burial .c 197, (If body is to be temporaril11•held, fill in spac later) The CERTIFICATE OF DEATH contai ing the above stated particulars, having been presented to me, afte careful examination, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registration, ve recorded it in my Local Record with the above stated Registered Number, and on the basis� thereof I HERE- BYRANT A PE MIF c'e y K AO Jf the .__ GILL.._. to hold temporarily and ! ( the body (Unlertaker or person having charge of corpse) ('�� memo a or oth wi• ' pos of ate how)) Dated `)?%<—may _a, 19._7-7 (Signed) Q 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. FORM VS. 61. (REV. 6/63) (8A2-781 ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS. ARE MADE Date of Interment was May 24 1979 (Interment or Cremation) St. Alphonsus Cemetery (Name of Cemetery, Crematorium, etc.) Section 1-Grave Lot No. Grave No. (Signed) (person in Charge) Address 35 Broad St. , Glens Falls, NY 12801 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) DAYS with the Registrar of District in which cemetery is located. 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 DOL- LARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Regis- trars are required, under penalty, to report violations thereof.