Ten Eyck, Rose Form VS sL NEW YORE STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to This Permit can ha 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.Dist. _
Village Schenectad
y
(If city, give street address)
Name of deceased Rose Delima Ten Eyck Veteran
(if veteran, give name of War)
Single, married, widowed,
Sex..EeTal.e..Color Wl .te.or divorced (wnte the word)...SPparAted. Date of Death Junx 5— 19...62
AgeZ9 Years— Months Days Birthplace Glens Falls.s.Naia
Cause of Death ArteriQUlArAtig Heart disease
Certificate was signed by S. Resnick M.D.
Address 1221 U.nio.n..St..
Place of Burial (or Removal) Glans..F.a,7.. .... ai
(If body Is to be temporarily held, fill in space later) June 7— 62
Cemetery St.....A1,phca ••• Date of Burial 19
(If body Is to be temporarily held,fil. n s r)
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 fore registration, have recorded it in my Local Record with the above stated Registered
Number. MA °r. 'an$alcen thereof HEREBY GRANT A PERMITlsle: Funeral Home 1867 State St.
to
(Name) (Address)
the Ulidefrtaketr to hold temporarily and Inter ,. the body.
(th deryiffer person hsvi8gchargeecorpse) (Inter,remove, otherwise dispose of[s ow])
Dated ��uu�i 19 bb (Signed) . ....--- .... . .. .........
Local Registrar
This F;armit is sufficient for the Removal (and Interment or Cremation) of a y o any part of the State (aubj to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is req .
ENDORSE1LENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ofy64'�1-- --2--,^-,- was 14 �—
(In terment or Creeg ion)
(Name Cemetery, Crematorium, etc.)
Section / Lot No. urave No.
(Signed) (*N• ��`'��""4_(person in 24..4711ri
)
3 S•S' 3 X
1 -31"247(.2
Address
' Pepa2.e/ P
Person in charge gust return this Permit to
1,
the Registrar of his District within SEVEN (7) DAYS
fran 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.