Cohen, Ester Form VS.!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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...
4601 Village
Dist. No County..._.....S.thRIle A[dy or City Pt)4 EU1,s..h.Q.spita1
(If city, give street address)
Name of deceased EAte.r..CQ11,011 Veteran fQ
Single, married, widowed, (If veteran, give name of War)
Sex fern Colorwhite or divorced (write the word) widowed Date of Deatl1 Rixv. 4 19 62
Age G Q Years Months Days Birthplace
Cause of Death Cranio Cerebral trauma & crushed chest
Certificate was signed by John..C.....51terJAB.i1a...CPT.QTA ' M.D.
Address $t....Glar.cshqsp., Schenectady
Place of Burial (or Removal) Glens Falls
(If body is to be temporarily held, fill in space later)
Cemetery Sarateflio Date of Burial Nov• 6 1962 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,....574 11,vaTi &lItnahan Glens Falls, N,'Y 4
(Name) (Address)
the lUndartalser to hold tem orarily and Inter the body.
(Undertaker or person having charge of corpse) (Inter, remove or therwl disnos of[state bowl)
Dated 11-5-1962 19 (Signed)... .....
Local Registrar 404,1
This Permit is sufficient for the Removal (and Interment or emotion) 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.
ENDORSE ENT OF SENIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of �-t was 19
(Interment or Cremation)
(Name of Ceme ry, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 0 .
rson in charge)
Address / I`'V*-^' , ...Q/�'•+'+�tL T �L J
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the facc of the Permit. the.,,nrds
"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.