Lemery, Elda Term♦6.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr TUe Pernik 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. —'TOW!! Registered No._......?.........................
Village
Dist. No 5726 County shi)sgton orei r Hudson Fall
(If city, give street address)
No
game of deceased dA' F' Lemer Veteran
Female white Single, married, widowed, Married (lf veteran. sive name of War)
Sex Color or divorced (write the word) Date of Death Jan• 8 t 1959 19
Age ' 61 Years Months Days Birthplace
Cause of Death Pelvic Carcinoma
Certificate was signed by Harry DePan v,, M.D.
Address Glens Palls, N.Y.
Place of Burial (or Removal) St. Alphonse de, Town tit eueensbury
(If body is to be po I held fill in space later) Jan. 12, 1959
Cemetery Date Date of Burial 19
(If body is to be temporarily held,fill in space later)
Ibe 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 saute for registration, have recorded it in my Local Record with the above stated Registered
Numiter,
'le onnl heebassisral hher fII HEREBY GRANT A PERMIT c. Hudson Falls, N.Y.
under taker (Name) i Mgr■•)
the to hold temporaril and the body.
(Undertaker or person having charge of corpse) (Inter, or dispose of state how])
Dated Jan. 10, 1259 19 (Signed) eputy
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.
ENDORSEMENT OF S1 X1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTENTS OR CREMATIONS
ARE MADE
Date of L s-te- was . / 19 d7
(Interment or Cr tion)
•
I ,
*r (A C — j .C,c •o �Q— yr.��.L-2t
(Name f Cemetery, Creme tPor�i�u`��,1D�etc.) I
Sedti� Lot No. Grave No.
.(Signed) ///,/��\/
(Person charge)
Address A---/ 6 Q 0
j ,
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fram 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.