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Blair, Chrystel NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT ISFP 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. — 7 D— Town, Village Dist. No. `.7 ©/ County L�/a.4 A - or City � If city, give street address) Name of deceased Veteran (If veteran, give n me of War) Single, married,widowed, Sex = or divorced (write the word) Date of Death 7 v 19• - Age _ gt/. . _ ,Years Monts _.. . D ys Birthplace • Cause of Dear Certificate was signed by! L•i,/-- - e_.4 M.D. Address /`� -.C.,+tR -�- Place of Buri. (or Removal) .._ /.. ._. (If body is to be •orarila-held fill in . a e' ater) / Cemetery.... `� �{ Date of Burial 7! �'u 19_ ; (If body is to be temporarc y-held, ill in space later) The CERTIFICATE OF DEA H 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 regist tion, have recorded it in m Local Record with the above stated Regis/ on, thereo (Number, th asis f I HERE- to GR A P R11 IT V ^.,%K id...,_, (� 2/4 ( ame) ) (Address) • the ' .._-q to hold temporarily and 7 the body (Unlertake or person having charge of corpse) (Inter, r ve, or erw• . dispose pf (state how)) Dated ./ ` 19.7 (Signed) r Local Regis r This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part f the Sta(A.3.2,, subject to local metery or other regulations), unless removal is by common carrier, in which case a Transit Permi (VS No. 62) is.-required. 1141 Vs. 61. (REV. 6/631 18A2-781 ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WI- CH INTERMENTS ( OR CREMATIONS AR: MADE Date of Interment was — 7-17 1979 (Interment or Cremation) St. . Alphonsus (Name of Cemetery, Crematorium, etc.) Roger Section Single Gravl6bt No. Grave NoJ�ef Guy- ette - ` ---- (Signed) (Person 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.