Chadwick, John Form TEL EL NEW YORK STATE DEPARTMENT OF HEALTH - --/ 7
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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.__.._..__....._._
Ariaft
Dist. No 575o County #a hingbon xol Argyle
(If city, glee street address)
Name of deceased John Ckla wiG. Veteran No
(If veteran. give name of War)
Single, married, widowed,
Sex...Maaee....Color....Yht.t.eor divorced (write the word) W.7 d.ow d Date of Death..:May. nth.. 19..57.
Age P2 Years Months Days Birthplace G.a..n.S...F.d.i.1.S.,....N......Y...
Cause of Death Cerebral Hemmorhage
Certificate was signed by Roy...E...,...:3.QX:X'A.W.TAaf M.D.
Address Fort...Edw.ard......ri.... .Y..
Place of Burial (or Removal) Queensbury, Warren County, N. Y.
(If body is to be temporarily bel ell in space later)
Cemetery Mount Hermon Cem Date of Burial May 14th. 19....57
(If body is to be temporarily held, ell 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...Car :C .PIl..F.un ral..RQ?Aa.,.iac.,.By....A1taQn. C . Wils.on Hudqon...Falls,....N.....Y.
Undertake inter (Address)
the to hold temporarily and the body.
( T dertak Jerson having charg corpse) (In remove,or oth lse r¢e f [state how])
Dated iviay �� i• 19 (Signed) .frgeg-
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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMAT! S
ARE MADE O ct�R
t
Date V-o r'� '�-•--/ was / 1957
(Interment or Cr tion)
(Name of Cemetery, trratortum, etc.)
7
Section l Lot No. 1 Grave No. '
Si ed ` ✓� /12( gn )
(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.