Hubert, Augustus Form V&6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
cr 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. Town Registered No._...._...._........_
4 56 2 � e
Dist. No county .r cxs cld'Stx glom u.
s
(It city, give street address)
Name of deceased Augustus Hubert Veteran no
Single, married, widowed, (lf veteran. give name of War)
Mai White gWi4ke=i Feb 5th 58
Sex Color or divorced (write the word) Date of Death ham a 19
Age 89 Years .Months Days Birthplace Pl t#•,.•.H•aXR
Cause of Death A.S.C.7. Disease Gen . Art. Sclerosis
Certificate was signed b Alexander Avrin M.D.
Address 32 Sherman Ave. Glens Falls,N N .Y.
Place of Burial (or Removal) St. Alphonsus Cemetery Glens Fad: •g,N,AX.
(If body Is to be temporarily held,fill in space later)
Cemetery St. Aiphonsus Date of Burial Feb. 7th , 19..:.8.
(If body is to be temporarily held,fill in apace 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 Donald Clark MaIn...St.. outh..Glens...Fafl&,N•.•Y.
(Name) (Address)
the Widertfikex to hold tempos nd rote the body.
(Undertaker or person having charge of corpse) (In r,rem ea ose of[state how])
Dated Feb. 5th 19.58... (Signed)
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat of the State (*abject 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 SEX1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE •
9- ') l "
Date of • was 19
(Interment or Cremation)
(CI
(Name o /Cemetery, Crematorium, etc.)
Section Lot No. Grave No._R_
4
e1,1 /
(Signed) /
(Person in charge)
L)Address
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.