Shattuck, Helen NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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.
Town, Village Registered No. 171i 6 '
Dist. No. 5601 County Warren or CityPlens Palls Hospital
(If city, give street address)
Name of deceased Helen e hatturk Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex Female or divorced (write the word) Married Date of Death Sept. 30 19 70
Age 61 Years 3 Months 7 Days Birthplace SandyHill N.Y.
Cause of Death Coronary Occlusion
Certificate was signed by..Joseph "Foote M.D.
Address Fort Ann N.Y.
Place of Burial (or Removal) Twn Queensbury Warren Co N.Y•
(If body is to he temporarily held, fill in space later)
Cemetery We.s.t...Glens...F.al1s...N..Y, Date of Burial 10-5-70 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 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
toc..r.le.t.on Funeral Home Inc. (A,C,Wilson) . Hudson Falls N.Y.
(Name) (Address)
the Funeral Director to hold temporarily and Inter the body
Dated(U nd(,Gtober ker or person having charge of corpse) (Inter, remove, or otherwise.�dispo of (state how))
3 19 70 (Signed) 72}o istrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any p t of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (V o. 62) is required. _ a41E4
FORM VS. 61. (REV. 6/63) (9A2-205) <=0
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 4 L �s A"%r
19 7?)
• (Interment or GRamatinn)
(Name of Cemetery, Gremaeeriam, eee.)--...
Section Lot No. Grave No.
(Sign
j • (Person in Charge)
Address /4°*l""--Qj
Person in harge 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.