Nabert, Maria Form VS.sit. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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. To, Registered No
Y 6 -Village ,� .
Dist. No County...led -,r— or Clty --- ..____ .- � 7'C4,/ ,,_ /,,,
•• / (If city,give sdress)
Name ff de eased ( e/ Veteran
/ (If veteran, give name of War)
E Single, married, widow , _
Sex Color � or divorced (write the word). ``... . .. ......... . ate of Death....,t-4,.,G...�.. 19�
Age YV, •s..,. MonthDays Birthplace �'
Cause of Death-..,: . . .... . ., ---'�' -�-a..
Certificate was si ed by24--(K" ---,
;A :Address. y..l � .. . -� M.D.
Place of Burial ,(or Removal) 'mil �-� ,� -2 : }�� �
(If bodyis to be p9Carily,held :fill la pace later) 9 i�
Cemetery ti . -. -1 f-� K-•-u--o , r,-,..-•- Date of Burial �s..� , --7/ 19.;?..��
(If Dody is to De temporarily Deld,. 1 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, on/ basis thereof I IREBY GRANT A PERMIT ('
to......�. �,:l..f�..`�- ",/- :.�:t` :i, -4- 1-4-I . ii�l y. ,` (r4 �-
1' ) (Name) rl address)�
to hold temporarily and `--`,r Elie body.
the � �..-�:x ::a''-��-,___ >:..cz..��,- �, �,
(Undertaker or person baying charge of corpse) ,(Inter,remove,oc otherwise dis»ose of[state bowl)
Dated , ti 19.. .. (Signed) 7
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.
ENDORSEHENT OF Si:xiUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
•
•
Date of Interment was June 5 19 59
(interment or Cremation)
(Name of C etery, Crematorium, etc.) �R''�� ✓
Section Lot No. Grave No.
(Signed)
G TCA,Q-
&At(
raoa in charge)
Address P.O. Box 600, Glens Falls , New York
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.