Smith, Georgia Form vs.C. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERTIFACATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._._.. .._
3296 Oneida Village 1213 Court St. , Utica, N.Y.
Dist. No County or City
(If city, give street address)
Name of deceased Ge.orgia...Smi.th Veteran CIO
Single, married widowed (if veteran, give name of War)
SexFemale Color White or divorced (write the word)Single Date of Death Dec. 2 19..57.
Age 69 Years Ui. Months 24 Days Birthplace New York
Cause of Death .1.QbaX'...pne.UTJI.oJ:11.a
Certificate was signed by Ole.b. .11.....341alan.S1iy M.D.
Address. 1213 Court St„....Utl.C.a, N.Y.
Place of Burial (or Removal) Queensbury (Warren Co. ), N.Y,
(If body is to be temporarily held,fill in space later)
Cemetery PITO J Pw Date of Burial Dec, 5 19 57
(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, and on the basis thereof I HEREBY GRANT A PERMIT
to Carleton Funeral Home, Inc. (per A.C.lai 1, 4?:1l.. HudgQT...Eal.l.Q.,.. ..Y,.
(Name) (Address)
the LInde.r.taker to hold temporarily and .1nt.e.X' the body.
(Undertaker or person having charge of corpse) (Inter,rs�ove,or of disnoee of(state howl)
Dated Ue.G.,r Z 19. 7 (Signed) I...t 7........
ty.. Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) f a body to any part of� e Slate (subject to local
cemetery or other regulations),unless removal is by common carrier, in whic case a Transit Permit (V No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date /� � v wa -FQ1 5_ 19
(Interment orb)
212
77/
I flu Cs ",� `�`� � /1=�"_-
(Name of Cemetery, Crematorium, etc.]
Section t � Lot No.3't3 Grave No. `
(Signed) ,
(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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re—
quired, under penalty, to report violations thereof.