Rustin, George Form VS.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
nr 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 CERTIFICA E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No..-....LI _ —
Vie
Dist. No✓�� 7 County..-Warren or 6ityllinneseta..A.Ye...Tann...►ueezlsbucy
(If city,give street address)
Name of deceased George SA Rlatin Veteran no.
(If veteran, give name of War)
Single, married, widowed,
Sex ale...Coloi bite or divorced (write the word) 'Widowed. Date of Death...Oct...21 19 58
Age 83 Years Months 29...._ •D,ays Birthplace Mora 1 Na Y.
Cause of Death ,t'4-' ct�"',� ccetest'.•:/ a ,S � t''<',-ur`''9
Certificate was signed by W...11iain St.Jolla. M.D.
Address. 1.7 Pin.e..5.t....Q1ens FB,lIs..1I.j:....
Place of Burial (or Removal) Tuwti Queensbury 'warren Co, N.Y.
(If body is to be temporarily held,fill in space later)
Cemetery P .ne..Yiew Date of Burial October,.214 19..58•
(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 Carleton..b.mer..a1..JJome...lnc.. . on..F.alls..N.Y.
•
(Name) (Address)
the A.Ce 'ilson to hold temporari' and Inter the body.
(Undertaker or person having charge of corpse) (Inter,re ove,or of se dispose of(state how])
Dated..QGt.aber 23 19...Sfi. (Signed). a
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod to any part of the state (eubject to local
cemetery or other regulations),unless removal is by common carrier, in which ease a Transit Permit (VS No. 62) is required.
L,.fgyr.^-+ci `s s i- ---v
•
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREJISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date :-;.: /....
r was ✓1 19_La-
(In terment or
•
(2:)l'L''' .�
( me o Cei metery, Crematorium etc.) j
5 -1..,,4e4 }—A-0---.----E .
Section Lot No. Grave No.
14>
�- ,
(Sigeed)��1.-‘11L--XC.-:. !''p-yj_( ...
(person in charge)
3f-
Address`!!� a j ;/.
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.