Nelson, Gertrude recw WKK JIAIC IJCI'AKIMCNI Vr 1'ICALim
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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. .. 5-0 .
Warren Town, Village r1Pns calls
Dist. No. 56OL County or City
If city, give street address)
Name of deceased Gertrude Fdna Nelson Veteran no
(If veteran,give name of War)
female Single, married,widowed,
Sex or divorced (write the word) married Date of Death r'�ay 18 1976
Age 78 Ye Mont D ys Birthplace Glens F al l s, NY
Cause of Death �_c-s - - Q
Certificate was signed by .D r n i,cha r_d Hogan M.D.
Address 325 rain CA., T_Tudson---Falls-, NY 12839
Place of Burial (or Removal) Town of Oueencbur-y, NY
(If body is to be temporarily held, fill in space later)
Cemetery 'Test "lens ells ^Pmetery Date of Burial ''Ra%' 21 1976
(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 examination,
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 HERE-
BY GRANT A PERMIT
to Carltor T'linr' al omp, Tr' . '',1'4on ra115 , NY
(Name) (Address)
the rlinoral r`-i r^-roc intor
to hold temporarily and _.. the body
(Uhl ker or person having charge of corpse) (Inter move, they di se of (state how))
Dated � / 19__.7( (Signed) ..:
Local Registrar r.`
This Permit is sufficient for the Removal (and Interment or Cremation) 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.
FORM VS. 61. (REV. 6/63) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of --L'h1 t- 'v was r? �719 7
(Interment o+i-F'_ �?ian4---
ic....eai-2. -i-e .4-
(Name of Cemetery, etc.) i
Section Lot No. Grave No.
(Signed) a A---", ",„„)
(Person in Charge)
Address '}` / "-�- �
'%%e('
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 DIRECTO or
UNDERTAKER MUST SIGN ABOVE STATEME
write across the face of the Permit the words "No person I.
charge," and FILE PERMIT WITHIN THREE (3) DAY
with the Registrar of District in which cemetery is locate
4 SEXTONS, FUNERAL DIRECTORS and UNDE
TAKERS violating the law relative to the return of per
are liable to a penalty of NOT LESS THAN FIVE DO
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.