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Chicone, Francis NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tar 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 CERTIFICATE OF )EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. . Town, Village Registere 7.." . )ist. No. '--1 ,(e0,/ County 2V /,''`•-) or City (II city, give street a dress) , . dame of deceased e....z., '46:e. ei-4---91-4--- Veteran - -•••,A-4(-4'L (If veteran, g 'e name of War) Single, married, widowed, ,- iex --( '- or divorced (write the word) Date of Death 4 ••- -- age /........,....Year .Months ys Birthplace 19 7-ause of Death ....C OY.--- certificate was signed by a,,,, M.D. Address 0..-• ..T.X.,e Place of Burial Removal) •i.??, - If body is to he orarily held, in i'n't;Paie4-a-t-iefira -414/17 6/ • emetery inDate of Burial ,2_ ,' 19 If body is to be temporarily-held, fill space later) [he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the ;ame appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra• ion, hav- recorded it in my Local record with the above aced Registered Number and on th9ba is they of I HEREBY GRANT A 'ERMIT co 4(' -'21/1.4 --)- ( - 3/ lz- A ' (N-,”e A ' 4-,,a- cA ddr s he/ "2/.., ' 4.,---#.... / to hold temporarily and the body erta&dr gotrs• 7ving charge of co Se) --nlove o -oth rwise dispose of (state how)) )at-d ) c 19 7 (Signed) , -.......> jal'Registtar This-Permit is su ficient for the Removal (and Interment or Cremation)of a body to any par "if the State (subject to local cemetery or )ther regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. FORM VS• 61. (REV. 6/63) (3A2-323) ENDORSEMENT OF SEXTON um YEKJON IN LriHKVC, OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of ,�;. was 9 19 7 (Interment or :Cremation-)----...`„ (Name of Cemetery, Crrmatori„m, _) Section " L Lot No. Grave No. • (Signed) i• -4 (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 UNDER- TAKER 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 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 required, under penalty, to report violations thereof.