Dube, Bernadette NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ra' This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. U
Town, Village Registered No. A7
Dist. No. 5601 County or City Glens Falls, NY
(If city, give street address)
Name of deceased Bernadette E. Dube Veteran 11a
(If veteran, give name of War)
Female Single, married, widowed,
Sex or divorced (write the word) MaXried Date of Dea .Bill 19 73
Age 73 Years Months Days Birthplace Canada
Cause of Death _ Si ps4\ —;•1\
Certificate was signed by�� 8 -".. ., c-'�Q, M.D.
Address 325 Main Street - Hudson FallA, NY
Place of Burial (or Removal) .... . .. West Glens Falls, NY
(If body is to be ter�p� x ratiPlphehodnsus space later)
CemeteryDate of Burial 8/1,4 19 73
(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
Carleton Funeral Homer Inc. Hudson Falls, NY
to (Name) (Address)
the E.W.Wil son to hold temporarily and inter the body
(Undertaker or person having charge of corpse) ( , removini oth s9eusz of (state how))
Dated 13...)0l.f ...(.. 19 ?) (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to ny 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
l /i
f
Date of d� f was ab 7y Or 19 73
(Interment or Cremationli
ii. c 62 "'
(Name of Cemetery etc.)
Crematorium,
Section 'i OL) Lot No. SC) Grave No. -5
..
(Signed)
( erson in Charge)
Address 3 5 3-rna 4j 4&?1,o ?ctXJ�o IU: I,
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above dat no
person is in charge, the FUNERAL DIRECTOR or U R-
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge," nd
FILE PERMIT WITHIN THREE (3) DAYS with the Rear
of District in which cemetery is located. in
1
SEXTONS, FUNERAL DIRECTORS and UNDERT RS
violating the law relative to the return of permits are lia to
a penalty of NOT LESS THAN FIVE DOLLARS NOR M RE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.