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Flewelling, Lewis NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT igir 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. V ` Town, Village Registered No. ( Dist. No. 4t County "'� 1 or City �,r.'-i .......'�"'� _ (If city, Ce street address) Name of deceased �t�w^-►r Veteran vj.... w v (If veteran, give name of War) Sex (IAASingle, married, widowed, (TNor divorced (write the word) .....1 Date of Death Y- f t' l`"'T 19 ..7.`� � '`e� Age ..� Years Months Days Birthplace � - -- .... Cause of Death Certificate was signed bybeke—tsft=-"P M.D. Address jie- ANA ji-- 4" -A-a4, `"? Place of Burial (or Removal t ,-LcYe �,+... (If body is to be temporarily held,hill'in space la r) „ _ jJ Cemetery to he temporarily held, fill in space later Date of Burial ttfj-1 19,7 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 r ,Q,c) `3 Y Q (,, ~ � (AddresfL s ' " the 401,, . to hold temporarily and ti.--- , the body (Undertaker or persog having charge of corpse) (Inter remove, or otherwise dis ose of (state how)) Dated V }-- - 19 ."'I�... (Signed) —�--�. lR_ C— (/ 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 of :1 was (Interment or Cremation) (Name of Cemetery, Crematorium, etc.) L / Section C, �' Lot No. //7 Grave No. ,� (Signed) j r; ( %` (Person in Charge) / / 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 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 retumrof 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. FL 't+TLLLING, Lewis Age: 79 Cause: Bronchopneumonia Lot Owner: Allen Flewelling Lot # 37 A, Una dilla Plot Ext. Grave # 6 Case: Concrete Died. 4/19/74 Interred 4/23/74 singleton Undertaker: FLEVELLING LFIt No. d� Address 41 Cottage Hill Rd.. Glens Falls, N.Y. Section 3: Owner Allen P. Fiewell i n & Lottie M. Flewelling Plot Unadilla Ext. Date.. 8/2/73 200 Superficial ft. @ $2.00 per sq. ft. Location Bounded on the North by Vacant, East iyPath, South by Vacant. West by Road Corner Posts Remarks Deed No. (and changes) 1�77 Payment Record Paid in full 8/2/73 Form No. 01 Record of Interments 1 Allen D. Flewelling 12/10/01 I5 r, z �1_.at$ mPtcz�e. T\ci,. �;'� a - - asr 6 Lewis F1ewe11in2 (li/21/711) 31 I7I 4 I8 P,9TII 1©' J I E „3._ . Lc:- Ate- ! -1 i 4 . I I X I / I . x 1