Scott, Leemond Form VS.!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1r 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 CERTIFICAT OF
DEATH. LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._
Village
Dist. No 4562 Count,, _Saratoga or City Town of Moreau
(If city,give street address)
Name of deceased Leemond H. Scott Veteran ,a7 :iv. II
(If veteran, give name of War)
Sindowed,
sex male Color white or divo divorced (wntele, married, lthe word) Date Date of Death Sept. 4,1962 19
Age 55 Years Months Days Birthplace ?ovaScotia
Cause of Death A.s}slaysci,aa.ue...tra.drou ,stag
Certificate was signed by Harold L. Ball, ornner M.D
Address Greenfield Center; N.V.
Place of Burial (or Removal) Town of Queen sbur ..� .Y.
(If body is to be temporarily
Uem�tei later) Sept. 7,1962
Cemetery Date of Burial 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 James F. Singleton Cilmu Fal.],g, '....X.t
undertaker r (xai�e] (Address)
the ,James ingleton) to hold temporaril and inter the body
(Undertaker or person having charge of corpse) ( nter, res3av , tithe se.disnose,of[state bow])
Dated 6eg:t.....Q.,.1962 19 (Signed) ...
al Itegistrar(se .1
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ("abject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o e- (--_ - was-- 19 2- —
(in anent or
Name of Cemetery, Crematorium, etc.)
f•',
Section -2----_ Lot No.Y1 Grave No. C
(Signed) � ' ' - '`� �%T (7-41
( reon in charge)
Address / �
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 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.