Vandenburg, Gordon Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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. .._229...._
Village
Dist. No.198. County...Al RILY or City 113 Holland Avenue,...A j4py.., .Ngw,.YQrk
(If city, give street address)
Name of deceased Gordon L. Vandenburg Veteran W I
Single, married, widowed, (if veteran, give name of War)
5ex...i4a:l5. Color White or divorced (wte the wrd) Married Date of Death 6/5 19 62
Age 6 Years Months Da Birthplace New York
�ause of Death Bronchopneumonia, ex'ixeiilive;�sbilateral p
certificate was signed by....Jlrazia..R....Zumho M.D.
Address V.A. Hospital,, 113 Holland Avenue, Albany,1 New York
Place of Burial (or Removal) Town of Queensbury,, New York
(If body is to be temporarily held,fill in space later)
Cemetery We;3.G..G.len.a..5.a1.1s Date of Burial 6J8 19..42.
(If body is to be temporarily held,all 1n space later)
Tie 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
;o 5m11ivali & Minahan Funeral Home, Inc, 67 Park Street,,Glens Falls,, view York
(Name) (Address)
he ljndertaker to hold temporarily and Inter the body.
(Undertaker or person having charge of corpse) '" 7 (Inter,; move,o,�e ae dispose of[state bow])
Dated bib./ 19.62.... (Signed).; I`� , .t__
-' Local Beg atrar �—
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (subject to local
:emetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was 19 C -2 -
(Interment or, j
(Nerve of Cemetery, C ematorlum, etc.)
Section Lot NO. Grave No.
•
(Signed) 7 .
person 1n oharge)
Address (re,k11,194,
Person in charge must return this Permit to
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 lords
"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.