Moore, Tressa Form vs.AL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt 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 Registered No.__.._.26
..._....._.._
26 'dash. Village Hudson Falls
Dist. No 5.7 County or City
Tressa A. Moore (If city, give street address)
Name of deceased Veteran no
F'e_ � — Single, married, widowed, *idolrt:d (if vet May give
1961eof ��
Sex Color or divorced (write the word) Date of Death19
Age 78 Years Months Days Birthplace Brockport* N. Ye
Cause of Death Cerebro-Vascular Hemorrhage
Certificate was signed by 7. Latimer, M.D.
Address Hix4Kox1..E.a. ; ,..g
Place of Burial (or Removal) Tn, of Queensbjry,, N. Y,
(If body is to be temporarily held,till in space later)
Cemetery Pineview Cem., Date of Burial Mai 8, 1961 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 44i7i S...F......5 :IJalgtP.1x,. Glens Falls, N. Y.
the undertaker to hold tempos 1 int (Address) the body.
(Undertaker yrvertical,having charge g orpae) er,remote, o se too a of bow])
Dated .a�, bp I b (Signed) Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past 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 SN'X'IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date off` 4/e was /Cr 19 ‘P
(1 4ermant or
7.
/� /lcw zc I
(Name of Cemetery, Crematorium, etc.)
Section > 7' Lot No. 1 J Grave No.
(Signed/)
(Person in charge)
mil/Address(L ��/� X �e-� Ae= - -f -_
Person in charge mast 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 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.