Kenyon, Josephine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Viltage, 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. ?&3
Town, Village Registered No. .7
Dist. No. 5601 County Warren or City Glens Falls, NY
(If city, give street address)
Name of deceased Josephine Royd Kenyon Veteran No
(If veteran, give name of War)
Female Single, married, widowed, Widow 6/19/73
Sex , or divorced (write the word) Date of Death .. 19
Age 89 Years Months Days Birthplace Hartford, NY
Cause of Death Bronco-pneumonia
Certificate was signed by C.V.Latimer M.D.
Address 100 John Street Hudson Falls, NY
Place of Burial (or Removal) Queensbury, NY
(If body is to be temporarily he d,..fi11 in space later)
Cemetery P ..O.eY. ,t'iN CemQ.tery Date of Burial 6/2 /73 19
(If body is to he 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 a.ppearing 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
to Carleton Funeral Home, Inc. Hudson Falls, NY
(Name) (Address)
the E.W.Wilson to hold temporarily and inter the body
(Undertaker person having charge of (Signed)
nter, removyhrt erwts•o dispose of (state how))
Dated 4 xise)—I4d 19 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. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
/ r
Date of G L �1<C-t rt. as ;. t 1C( x) 19 ��
(Interment,or ri).__
(Name of Cemetery, Csrrm.,. e .)
Section • 2' Lot No. // Grave No.
/ r
ti`
(Person in Charge)
Address t�
6--Z � e i <_('Z-ram
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 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.