Selleck, Leslie Form S.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 TQWnI Registered No._....._...._................_
Village
Dist. No.;,.::ate.. ....County..._.QS1RIc?.a. L o -ci i Manlit_s a TT.
(If city, give street address)
Name of deceased 14e.S.1.7.E�...ae.11.Qcli. Veteran :iQ
Single, married, widowed, Of veteran, give name of War)
Sex hale Color I r±te or divorced (write the word) ,n..:1.21'-:,:Lei Date of Death....Jafl.,:. y...17 195.1..
Age 72 Years Months Days Birthplace Glen Falls N. Y.
Cause of Death C.OS:.cL1G.r.y....QfClusi..Qfl
Certificate was signed by Pau.1...Bis t M.D.
Address. ''-GL:.. a.rette..St.,.
Place of Burial (or Removal).........0:. ;75... ''i;..?.1 2....i...< <
(If body is to be temporarily held,fill in space later)
Cemetery -1: :...;i.-. :..C.P.::1 Date of Burial Ja3.-Luar.y....2.0 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 exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to k air.c1 1.a.d...&..1L.c. .......... :...W.......Qacm.6.a=. . : ......5. a&?::"e , 4
(Name) rater (Address)
it r the body.
the tild,.X:.e. ...:a,Q.T to hold temporaril and Y
(Undertaker or person having charge of corpse) ( tit remove„or otherwise dispose of [state how))
Dated J.araalal:y....1.7 19 (Signed) .. ,r:.,. „ ..JY .: 4. '
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio 2 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 SENIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
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7 was- 7-J‘-- 2, / 19(Interment or,Voirerrehon)
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_....._..
(Nese of Cemetery, Cress torlysk, etc.)
-7
Section , .,"--- Lot No./ 527 Grave No.
...........--/' ,
(Signed) ..."24" -,',-..56(••---... ."ti C.-'7 2 (--
(Person in charge)
.
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Address -' Z 0'.-1 . ' ' , , „:.:.__‘ A,
Person in charge must return this Permit to ,..17
the Registrar of his District within SEVEN (7) DAYS
from 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.