Smith, Milessa NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
' This Permit can be signed only by the Local Registrar (Deputy cc 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, Village Registered No. l
Dist. No. 5601 County Warren or City G1en.s....Fa11s.,...NY
(If city, give street address)
Name of deceased Milessa (Holly) SMITH- --- Veteran No
(If veteran, give name of War)
Single, married, widowed, 3/6/73
Sex Female or divorced (write the word) Single Date of Death 19
Age 5 Years Months Days Birthplace New York
Cause of Death Welms Tumors in Metastic to lung....and,.,. . ;ve.:
Certificate was signed by Dr, William Simmonds - Harrison Avenue Glens FaUs., NY M.D
Address
Place of Burial (or Removal) .... . To.n..Olf queen.s.bury
(If body is to be temporarily he d, (ill in space Or
Cemetery Pine VLew Date of Burial 3/8/73 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 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 Carleton Funeral Home, Inc. Hudson Falls, NY
(Name) (Address)
the E.W.Wilson to hold temporarily and inter the body
(Undertaker or person having charge of corpse) (Inter, r ove, or o rwt a di ose of (state how))
Dated '? 19 ,3 (Signed) ... /
Local
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any p t 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
Date of v---a"' 2 /"" /was 19
(Interment or Crsrr),
(Name of Cemetery,
l/ <l.i jf I.rl,/` s —
Section Lot No. �_� - Grave No.
(Sig
(Person in Charge)
r /
Address � ', t r i"-"( - -
r rl 1-7/7 //
—Person in charge must return this Permit to thVRegistrar
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.