Potter, Rodney Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town Registered No—_..
Viliege
Dist. No..5657 County Warren orEity .Ri.dge..Boad..Ioun...Queensbury
(If city, give street address)
game of deceased....BQD Y...B....Pl.1ITE8 Veteran no
(If veteran, give name of War)
Single, married, widowed,
Sex.hae Color.. ite....or divorced (write the word)..Macried Date of Death*...29 19...42
Age 73 Y rs J.1 rMro 12.._ ..Days Birthplace.S IIMQ.vus..N..Y.
Cause of Death.Certificate was sigi ed by...Q.barieA Hawkins M.D.
Address..Z. ay....treet Glens Falls N.::A
Place of Burial (or Removal) Toi& ...Quef nsbury Warren.Q.Q.....N.Y..
(If body Is to be temporarily held,till in space later)
Cemetery Fri.eaci& Date of Burial June 2 19...62.
(If body is to be temporarily held,fill In space later)
Thu 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 qii the basis thereof I HEREBY GRANT A PERMIT
.o Carleton runeral Home Inc. (A.C.1'1ls on). Hudsgl 1411$ N.Yx
Funerals (Name) (Address)
�' the body.
Ile ��, �:e.�t.Qr to hold tempor and....Inter Y
(Undertaker r tenon having charge of corpse) (Inter,rem of a dispose of rata )
Dated May :11.1, 19...62.. (Signed)
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of body to any part of the State (subject to local
eemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
ENDORS.RIENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
,--: cl
Date Ga., was , -2--- 19(�2_—
or C an)
c
"I'44'21----(___
(Name fof Cemetery Crematorium, �)
Section Lot,, No. Gave No.
(Signed) L-1l'ZRY�f''-2f/)/I/�?
(Person in charge) _/
Address ' -7c-f/Fittfr . —.A g--- - /
Person in charge oust 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.