Davis, Nettie "-.
NEW YORK STATE DEPARTMENT OF HEALTH . 'a
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1:47" 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. _
Registered No.
Town, /
Town, Village pr,_
Dist. No. LI 7..1:-.,. -- County .- A--2-4-7-- , or City ,..7 c 2.4
t. (If city, give street address)
•
Name of deceased
,).,,,, /„..,-,.. „.&"-&--(...-4-(_.: Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex .-i-c----rk,-0.-t-c._ or divorced (write the word) ....X.7../L./././-,-4-1.-4- Date of Death sila " 19 .70
Age 7.3 Years Months Days Birthplace 2-7-f-w 94a-2-I--
Cause of Death 01.A.44.--,-.... ,r- „...,„...-64--4-2-el ,.
Certificate was signed by
- 9.,,c1----f---, M.D.
Address ---2'F/ //.-1-b ,.a----e,.. d--, .,/di-,----2 ,..)7,'J-i-, •I:. _, . ,
,....-
Place of Burial (or Removal) i 6-I.'', 17
1 )'
If body is to be iemporarfly held, fill in space later) 7- -
. --
Date of Burial - .1-( 19 7 4 e ‘..,
-emetery .,--, - — .. 7
-f.-
;If body is to Re 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 ,,-)
,, 7,- n -. ;,-1 ./
to 7Ce-r-2-1 Y- Xi A--'0.--,,-,-,.. V,.-- d•`// X.,(--t-->, s"...1-'
,.
(Name) (Address)
the y„e().--4_, „ - .. to hold temporarily and .....A_ - /7 the body
(Undertakpr or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated ,--4--a- --:;) 7 19 7,-, (Signed)
i•t
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
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM vs. al. (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of ` was '� 19 7
(Interment or Crematies)
(Name of Cemetery, C
j��-//fj / ./CIZ ri(-
Section ,Cv Lot No. T Grave No.
'✓� '0��
(Signed) 4 "z`7z,t_
(Person in Charge)
Address `) ..6.- t--L. ('/—t",e'
Pe n in charge must return this Permit to the Regi rar
of his District within SEVEN (1) 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.
L
147 Broadway
Fort Edward, New York
February 27, 1970
Mr. Joseph H. Sterzinger, Director
Bureau of Vital. Records
$4 Holland Ave. r'
Albany, New York
Dear Mr. Sterzinger:
Enclosed herewith is a "Corti-
ficate of Death" for Nettie Davis. Through error
the first "Certificate of Death" for this person
and the burial permit were issued by the City
Clerk of Glens Falls, Warren County. The above
named person actually died in the Town of Fort
Edward, Washington County.
In accordance with telephonic
instructions obtained from the personnel of your
office en 2/26/70, the original death certificate
and burial permit have been ♦oided, and a now
death certificate obtained and this office has
issued a burial permit. This will explain why
the issuance date entered by this office is
after the actual burial date.
Yours truly,
ea Edith M. Amorrsi
enc1-1 Town Clerk
Town of Fort Edward