Kathan, Jesse Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTIFIPATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No........... s..-.
Town
Dist. No 5601 County 't" arrr
er Village..1.....c.11 S.?.....:..t'xeet.4 G el?.5.... aa. is.,...N
or City (If city,give street address)
Name of deceased J e s e Fay Ka the n e. .
Male White Single, married, widowed, �,,,arriei' •- rch `'9 40
Sex Color or divorced (write the word) Date of Death 19
Age 73 Years N Months D Da s Birthplace... Con lin ville, N Y
Cause of Death �arc4 •of stomaXk -5 months-chrorile mvocarcitis 6 months
Certificate was signed.by Tarn`'s -i e Y , P: M.D.
Address �2T t�ien Street
Place of Burial (or Removal) Town,of "ueensbury, New 1'4rk
(If body is to be tRalp ily lek,fill c`enaee�iatetl�T 1"ij r i' 1 e t 4 0
Cemetery r 1 rr1 E'I� Date of Burial 19
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, 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, d basis thereof I HEREBY GRANT A PERMIT r
to -aro°i��. -'taffr( ?1 Glen Street
undertel4 e) Inteddreas)
the to hold temporarily and the body.
(Ule kart or.person having chargg At corpse) ... ...(Inter,r mov rho asi,se dispose or[state how])
Dated A 3:1 1; 19't U (Signed). �/
...
Local Begi:•ar
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.
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