Hart, Edith Form vs.si. 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.__._.....l_........_ _
5726 .Wash Village Hudson Falls,
Dist. No County or City
(If city, give street address)
Name of deceased Edith M. Hart Veteran no
(If veteran, give name of War)
Fe— wh_ Single, married, widowed, Widowed Mar. 1 63
Sex Color or divorced (write the word) Date of Death 19
Age 7.2 Years Months Days Birthplace Prov. Ontario, Canada
Cause of Death Broncio—Pneumonia
Certificate was signed by C. V. Latimer M.D.
Address Hudson Falls,N. Y.
Place of Burial (or Removal) Town of Queensbury, N. Y.
(If body is to be temporarily held,fill in space later)
Cemetery St. Alpilgr.1, 14 Date of Burial Mar. 4A 1963 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 Sullivan & Minahan,Inc. Glens Falls, N. Y.
(Name) (Address)
the 4xtde.rtakez Z•.•F .••Zli•rial4aR to hold tempora ' inter ex the body.
(Undertaker or person having charge of corpse) r,remove,o se ore of bow])
Dated Dkx'.,...1.,. 19..6.3.. (Signed) .z
Local
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTIgtMENTS OR CREMATIONS
ARE MADE
iftDate of L L was 19
(Interment Cr c e)
(Aare of Ce tery, r Corium, etc.)
Section Lot No. Grave-No.
(Signed) G� 1
rem in charge)
� GO
Address ',� O l
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 UNDERT4HER 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.