Genier, Medore • 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. 3295 County Oneida or City Rome
(If city, give street address)
Name of deceased Medore...Genier Veteran Na
(If veteran, give name of War)
Single, married, widowed,
Sex Male or divorced(write the word) Single Date of Death July 2., 19 ...7.5...
Age 81 Years 1 Months 4 Days Birthplace Glens falls, N.Y.
Cause of Death Artereo selerotic cercbrq vascular heart disease
Certificate was signed by Dr McDonough M.D.
Addresi.Rome Developmental Center-Box 550e Rome, NY. 13440
Place of Burial (or Removal) .... , a-c=•'� s a? ,-rv_, y4:.. -7i,
(If body is to be tempor i,1 he Il in spacd later) _—
Cemetery 2.;:A-e..�-a,cr�z- - -67fr,- Date of Burial 7— 9 197 S
(If body is to he temporarily held, fell in space later) I
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-
tio ave gcorded it in my Local Record with the above stared Registered Number `ancl,,on(y/tthhYe_�'baa�sis thereof I HEREBY GRANT A
iki ---..„ , ,,( -
awe) (A�dse.s.s�-._..,...
the `�' / [' s Co hold temporarily and `�sd•C< _ . the body
(Underta ttPson having charge of r (Inter, remove, or,otherwise dispose of (state how))
Dated ,.. 19 .: (Signed) ...: - se-- ,.` �1,... #j
l 's. Locr.liegistrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t 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.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of .t- -i-'Yl\- was 19
(Interment or Cre tion)
(Name of Cemet ry, Crematorium, etc.)
Section it Lot No. Grave No.
(Signed)
( erson in Charge)
Address S~S j),4• / 't-�1T od4 /C Y
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.