Lundgren, Erik Form VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH fr., ` /9 2/
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 Registered No.__.._....
•�" - �illagc
Dist. No ��/Gout ... ____.__c_„z,_e,L,„,..see
or City
e (If city, give street address)
Name of deceased a Veteran
Single, married, Widowed, (►f ve give name of War)
Sex* . ..CobO�or divorced (Waste the word) .... Date of ,....2 �.
Age �Q....Y ars Month .•....• •..Days 4• Birthplace . .. A. i
Cause of Death. e. ... .. ...... r I. .' • . .
Certificate was signe y�... v.� ',�r •e.. M.D.
Address cj C.K.... 40.'. .... - ' , 3
Place of Burial (or Removal ... .• '.. .. ...
(If body is to be polarily fll in spa ter) . .
'
Cemetery... ... �., Date of Burial ....�.- .. , 195.
(If body Is to emporarily held, fill In space later)
T'he 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 ha e accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num , and on the b is t f EREBY GRANT A PERMIT
to ,,,
' - I. (Address)
Na � ��
the .. .. to hold ten:pora ' y and thebody y.
(Lade ker o person hazing charge of corpse) (In , remove,.&o erwlse d nose of(state bowl)
Dated..... Yi 19k.7 (Signed) ... 4113'.c
Local R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of t t• (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREINATIONS
ARE MADE
•
Date of jwa9 19 7
(Interment o
\`ter
(Name of Ceme te ry,'Crematorium, e tc.)
Section Lot No.i Grave No.
(4(Signed) . 'Z
(Person in charge)
e B )
Address 1 G- .
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," anc 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 o ' 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, tojreport violations thereof.
LUNDGREN Lot No. 697
Address 130 Maple St. , Glens Falls, N.Y. Section N
4'. 26
Owner Mr. and Mrs. Thor A. Lundgren & Heirs PlotWah-Ta-Wah
Date 9-9-57
200 Superficial ft. @ 41.30 per sq. ft/ _ $260.00
Location Bounded on n/e by Wakefield lot; on s/e by grass path; on s/w by
vacant lot.
Jorner Posts
.emarks
Deed No. (and changes) 697
3ayment Record Paid in full 9-9-57 260.00
v
�v Y�
Form No. 01
Record of Interments
5
z � KY. `1-aS "4rv��5 s Eric B. Lund•ren —
3 7
4 Mabel Ann Lundgren 12/11/00 8
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LUNDGEN, Eri# D.
4....--o.-\\,
Age: 20
Cause: Ruptured Spleen
Lot. Owner: Thor A. Lundgren
Lot # 97, Sec. 26, Wah Tah Wah Plot
Grave #
Case: Copper
Died: 9W7/57
Interred 9/9/57
Potter
Undertaker: