Rivers, Justin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
£' 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. 4601 County Schenectady or City Ellis Hospital
(If city, give street address)
Name of deceased Justjn...E.....Rivers Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex Male or divorced (write the word) Married, Date of Death June...1.0 19 .7.5
Age 56 Years Months Days Birthplace New York
Cause of Death Fractured skull and subdural
Certificate was signed by Henry F.,.... amm M.D.
Address 9.09...Brand. .wine..Ave..-.,...Schene.ctady
Place of Burial (or Removal) Glens Falls NY
(If body is to he temporarily held fill in supace_late
Cemetery West Glens Fails Cemetery Date of Burial June 13 19 75
(If body is to he 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 Potter Funeral Service 136 Warren Street, Glens Falls NY
(Name) (Address)
the undertaker to hold temporarily and inter the body
(Undertaker or person having charge of corpse) -�l (Inter, turtle', or otherwise dispo of (state how))
Dated June 11 19 75 Si(Signed) -i A.,s6.:,. .. ;✓. : -<;1" I '
( g ) Local Regist r
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the Stat (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. St. (REV. 6/63) (9A2-205) Q
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o -1- was 19�S
(Interment or Q,-..w ._)
k`eti) 4// j f
(Name of Cemetery, ,Eshe r)—
Section Lot No. Grave No.
(Signed), „Civi
Cam '
/ (Person in Charge)
8,0, /
Addres
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.