Lemery, Alphonse NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rir 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. 12
5762 Wasington Town, VillageKin sour
Dist. No. County or City y
(If city, give street address)
Name of deceased Alphonse J. Lemery Veteran NO
(If veteran, give name of War)
Male Single, married, widowed, Married May 30 73
Sex or divorced (write the word) Date of Death 19
Age 78 Years... M nths Days, Birthplace Canada
Cause of Death Gneralizec1 Arterioscherosis
Certificate was signed by Richard Hogan M.D.
Address 325 Main St, , Hudson Fans,.. NX
Place of Burial (or Removal t.+lest Glens Falls, NY
(If body is t e temporarilyhe held, ins ace later)
Cemetery • ononsus Cemetery Date of Burial June 2 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
to Carleton Funeral Home, Inc. , Main St. , Hudson Falls, NY
(Name) (Address)
C. Bruce Wetmore Inter
the to hold temporarily an the body
(Undertaker,pu person having charge of c rpse) remove or o t state how))
Dated J person.L., 19 �' (Signed)
...............
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
Date ofPy‘tn-ru).-& was 1913
(Interment or Crem ion)
// hal1.CGS Cen'ifiery
(Name of Cerrfetery, Crematorium, etc.)
Section Ortr/ Lot No. 7 s,N Grave No. I
(Signed)
erson in Charge)
Address 35 13(OCtd �f) GienS Fails' Ai, y•
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.