Wiley, Charles NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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, Village Registered No.
Dist. No. 1650 County Franklt* or City Altanent
(If city, give street address)
Name of deceased Charles Warren Wiley Veteran Ies W W 1
(If veteran, give name of War)
Single, married, widowed,
Sex Male or divorced (*rite the word) Divorced Date of Death Aug. 16 19 75
Age so Years .Months* Days Birthplace Hew Terk state
Cause of Death Cardiac Ar='Ost
Certificate was signed by Robert F. Holt M.D.
Address Indian Lake, N,.1,
Glens Falls N
Place of Burial (or Removal , N. 2•
(If body is to be temporarily held, fill in space later)
-emeter a Vic., cemetery Date of Burial Aug. 20 19 75
;If body s 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-
:ion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to Richer Funeral Hesse Tupper Lake, N. T.
(Name) (Address)
the Funeral Direetert to hold temporarily and Inter the body
(Undertaker o person having charge of c.2rsse) (Inter remove, or otherwis dis ose of (state how))
)ated Aug. la 19 ..
(Signed) . .. . .. .. . .
Loca Regis
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the Stafe ject 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) (9A2-205) 9c
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was 85-())1e
(Interment or l�-re 't6Trj^--
(Name of CCete,ry, _ , etc.
Section '+ Lot No '`'''' 7Grave No.
L
(Signed •
(Person in Charge)
Address e e �L'�(
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 Distri+ot 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
t_:
law will be enforced; Local Registrars are required, under
penalty, to report violations thereof.
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