Street, Hayward NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilfage, 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.
Registered No. 1
Town, Village
Dist. No. 4562 County Saratoga or City Town of Moreau
(If city, give street address)
Name of deceased Hayward J. Street Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex male or divorced (write the word) Married Date of Death Jai, 7 19 .73
Age . .7 Years .Months Days Birthplace
Cause of Death Myo-cardical infarction
Certificate was signed by Donald L. Clark, Coroner M.D.
Address 136 Main Streets South Glens Falls, NY, 12801
Place of Burial (or Removal _Pine View Cemetery, Town of Queensbury, New York
(If body is to be.temootrilv h d. iill in space later)
Cemetery Fine view emetery Date of Burial January 9 1973
(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 appearing 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 Regan & Denny Inc. Quaker Road, Glens Falls, N.Y. 12801
(Name) (Address)
the undertaker to hold temporarily and tater the body
(Undertaker or person having charge of corpse) o MD. ..- •._-ose of (state how))
Dated JaqUarY 94 19 .73
( • 40, .ii.._, sir
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (su ct t
Local Registrar ocal 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
Date of..f1E/C 1 1/L� 4c/was / 7 19
(Interment or C )
1 -c L
(Name of Cemetery, Crernart--tstiurnr=etc..).
"/ 7ls'CCC et d C5/C/ � /�`'/7
Section Lot No. / -- Grave No., /71";!-zc
-'
(Signed'
(Person in Charge)
Address
7
P rson 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.