Wood, Olen Form vs.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
tillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.
fist. No? 3-0 County Warren. 110
# Bo.lt.on.
Of city, give street address)
Jame of deceased GLEN HENRY WOOD Veteran No.
Single married, widowed (If veteran. give name of War)
>exMale Color White or divorced (write the word) Married Date of Death December 2l, ,19..62
i.ge 59 Years —"" Months --- Days BirthplaceTn.. of Bolton, N.Y.
:ause of Death Acute Coronary Occlusion, Arterio—Sclerotic Vascular Disease,
certificate was signed by Clinton E. Lawrence, M.D.
Address Warrensburg, New York.
?lace of Burial (or Removal) Town...of QWeeno.bl ry,...New York.
If body is to beporaril eld,dll�In space later)
Cemetery Fine View Vault Date of Burial December 24, 19..6.2.
If body Is to be temporarily held,fill in space later)
rim Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
lation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
(umber, and on the basis thereof I HEREBY GRANT A PERMIT
o H. Edmond Brous Lake George......N.... ',
(Name) (Address)
he undertaker to hold temporar})y .d inter the body.
(Undertaker or person having charg of corpse) / �t , remove,or oth se disno f[state how))
)atedDeCtwmher 23..,. 19.2... (Signed) ,...Sc.�
.� apu g R
This Permit is sufficient for the Removal (and Interment or Cremaiion) of a body to any part of the 'fate (anbject 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 PHtSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was ems:. 19 Ca
(Interment or Creiletion)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
/ ,
(Signed)
l C-t
(Person in charge) L.
+
�.�,L
Address (,, ;jY'
Person in charge Mist 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.