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Ashley, Raymond NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT rgr 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 DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Cj 17 Registered No. �— I 56-54 (� e-�N Town, Village r JJ _ _ Dist. No. - County or City b© �l'C-Y\ ` CA) (If city, give street address) ame of deceased R{ . 1110 N G1. • ffSh Veteran 1�+0 JJ (If veteran, give name of War) Single, married, widowed, Sex rnL..�- or divorced (write the word) Date of Deatthy� I 19� p 1 Age 1/ Yea .Month Days Birthplace lf.eco Q(k0Q Cause of Death ,S.-a- Certificate was signed b Z",. M.D. Address V 0 *..1.. C... /�Q Place of Burial (or Removal) Pa& e V( �..(Al Y1. 'k-Q 4aj •�0 Go iv o-c" v.eeN$ tCte ;If body is to temporari y he d, fill in pace later � 2emetery t.)t?...- t C M.e, .�..1�j Date of Burial {-/ —I 1 19 ;If body is to he temporarily held, fill 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 accepted the same for registra- tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A PERMIT �^ :o"7- c�14iq S�tl(�ft�- �ut�iv�Yv �-(Yi(Np til�/U, � � Pal�.2 s� .�. -� 1�. /nevi. U (Name) (Address) :he (4Na.4�'�: 'K to hold temporarily d ikki-ei��, the body (Undertaker or person hav ng charge of corpse) (Int remove, or erwi how)) )ated 17/ L 0 19 ..� t (Signed) ... rtdispose of (- 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 )ther regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. FORM VS. SI. (REV. 6/63) (9A2-205) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of 1 14- as 19�/ 1 7 (Interment or 6remnrrtnr)— K..�C-e , (Name of Cemetery, Ciabala,ta . `1R L4 J Section ''1i Lot No. //G` '/Grave No. j1/4-4 (Signed) ''' (Person in Charge) Address / -/ � Lk 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.