Kenyon Sr, Charles NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CER-
TIFICATE OF)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village�, ry Registered No. 1
Dist. No....2- County Stew:,e or City South Cornin
(If city, give street address)
Nameof deceased Charles H. Kenyon, Sr. Veteran i o
(If veteran, give name of War)
Single, married, widowed,
Sex hale or divorced (write the word) i�arri act Date of Death...L.c.tSaber....1.3 19.23
Age 50 Years. Months Days Birthplace Florida
Cause of-Death Con estive Cardiac Failure
Certificate was signed by fan—DasilaiD M D
Address 173 E. First St. ,Cornin li„.Y. 1L830
Glenn Falls, N.Y.
Place of Burial (or Removal)
(If body is to be terry* Wilt Ali jn 9pgg_Igtar)er lr 7
Cemetery 2t 1t 1111 v :V tiC .Date of Burial October 1 2 19 2�
(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 Kaushe;Y Funeral Horse Cornin , .Y.
Name)
;rioip (A..
the Albert J. hau ey to hold temporar i er the body
(Undertaker or person having charge of corpse) ( ter,r o l.,or o .erw'. .(spose or[state w))
Dated t ctooer 5 1973 (Signed) 4 I , . .i_.' jI .
Local Reg!, rar
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, e2) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of ` ` C /1 4,4 as /` / 19
(Interment or Cret v
(Name of Ce r etc.)
Section Tot No. " Grave No.
4(Si necg �-
(Person in Charge)
Address / �—e,
i
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 `rNo person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict in which cemetery is located.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return ot permits are liable to
a penalty of NOT LESS THAN FIVE D?LLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.The law
will be enforced. Local Registrars are required, under penalty,
to report violations thereof.
CI