Shaver, Josephine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar- 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.
Registered No. G
Town, Village
�_
Dist. No. 5601 County Warren or City Glens Falls
(If city, give street address)
Name of deceased Josehpine V, Shaver Veteran No
(If veteran, give name of War)
Female Single, married, widowed, Married 12/5/74
Sex or divorced (write the word) Date of Death 19
AgeT Years Months Days Birthplace N.Y.
Cause of Death OA ri
Certificate was signed by 44tand Astin M.D.
Address 32 Sherman Ave. , Glens Falls, NY
Place of Burial (or Removal Town of Queensbury, New York
(If body is to be temporarily he d (iflin space later)
Cemetery WESt Glens Falls Cemetery Date of Burial 12/7/74 19
(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 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 Carleton Funeral Home, Inc. , Main St., Hudson Falls, NY
(Name) (Address)
the C. Bruce...Watmor.e to hold temporarily and Inter the body
(Undertaker or person having charge of corpse) (I r, remove, or of rwtse dispose of (state how))
Dated /o? - 19.2.V (Signed) �J`<-
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.
FOItM VS. 61. (RHV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date oi'4"� ''rf- was 'd�'/ 19/
(Interment or Ce twrr)----
117-e- 2
(Name of Cemetery, }
Section ____ Lot No. Grave No.
(Signcir
(Person in Charge)
Address 2 Zei
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 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 required, under
penalty, to report violations thereof.