Smith, Amelia Form vs.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit ran 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. Town Registered No—...........
It .rton Village 1 e
Dist. No 5 5Q Googly ashin Town of Ar>"or City Y
(If city, give street address)
Name of deceased Amelia Smith Veteran no
F emu Single, married, widowed, ((f veteran, give name of Wu)
Sex Color+Jhi t e or divorced (write the word) '`l id ow od Date of Death Dec. 6th. 19 58
Age 8l3 Years Months Days Birthplace Dresdon . N. Y.
Cause of Death Chronic Myocarditis
Certificate was signed by Q.y....E..•.....AZ'R 9.ttman. M.D.
Address. Fort run 'd N. y,
Place of Burial (or Removal) Glens Falls , N. Y.
(If body Is to tempo 1 held,fill In ice later)
Cemetery . Alphonse ��m. Glens Falls z 1`d•Y. Date of Burial Dec• 9th. 19...5
(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 SATISFAC!'ORY 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 Hugh W. Riley Hudson Fails . N. Y.
Undertaker (NaIDe) inter
(Address)
the to hold temporarily and the body.
(II ertaker oA person having charge orpse) ( ter,reme,o he [sta
te ate bow])
Dated ec :..' th. 19....)5 `v
(Signed) � i ....e....4
.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of th 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
0 PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
n
Date of "�,(k. .2,.- 012_ ,atwas '1 1/Z . • . 19S 7
(Interment or Cremation')
kl /1 / <r i - C, t i ,..� ,, �d cam, , ,.2 �
(Name of metery, Crematorium, etc.)
Section' li
'''^"i— Lot No. Grave . -3
t,i
r
1
(Signed) \D-Av
(Person in charge) ,
Address L )0v�( U e fir .,.., � .
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 fac , 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.