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Crosse, Florence NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT 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. l Town, Village ((�� Dist. No. -S60\ County CN. SuNr•. or City �2M� `� 4 If c' , give street address) Name of deceased_cS,_ ._ .__.__.CsZCT Veteran `\ __ (If veteran, give name of War) Single, married,widowed, Sex or divorced (write the word)4v�c=c�,a Date of Death . -1 19-79 Age 7© Years . Months Days Birthplace Y�i Cause of Death__._ Certificate was signed by .hCtV� 1 M.D. Address .-.-��}-Q ,-I- �� Place of Burial (or Removal) " tj Q (If body is to be t porari , eld fill in space late Cemetery Date of Burial .. '� 19 )7 (If body is to be temporarily hel , fill in space later) L 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE- BY RANT A PERMIT �/y� ` to -- - *- 1 ' ^)`(\ Shc ,-- 5 s - N` (Name) (Address) the W,ICJ✓ to hold temporarily and C` the body (U rtaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how)) Dated_.. _ .' -1 19 11 (Signed) y\(-V3CIA.(1,--f..J cal Registrar This ermit 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) I8A2-78) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of Interment June lg;,7 was (Interment or Cremation) St. Alphonsus Cemetery (Name of Cemetery, Crematorium, etc.) Section Sp•—E Lot No. A-4 Grave No. (Signed) )417i:::::LAL (Pers n in Charge) Address 35 Broad St. , Glens Falls, N. Y. 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.