Anderson, Raymond roan vs.sL 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,
tillage, or City) in which the death occurred after the FILING and acceptance of • CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town Registered No—_._.::._....._._
. Village _ r �,
)ist. No County or City -- .,. .,-e, , - n::' ,T ._._
(If c'.ty, give street address)
game of deceased - - Veteran
Single, married, widowed, (If veteran, give name of War)
iex -- Color .or divorced (wnte the word) -`:r' Date of Death , --J 19. ..4..
tge -' Years Months ,......Das, Birthplace., - " '''
:ause of DeathBronchogenl.c carcinoma,primary right lung,wit tracheal obstruction
:ertificate was signed by Orazio fit. Zumbo M.D.
Address V. A. Hospital, Albany, New York
'lace of Burial (or Removal)...W.�'nrL.rr Glens Falls, New York
If body is to be temporarily held,till in space later)
7.emetery at....A. P13.nSUS Date of Burial (— .- 19 6 ,3
If body is to be temporarily held,till in space later)
rim Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
iation, 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
p Roi<>=q>i Fpt}gral Service 136 Warren St. ,Glens Falls, New York
(Name) (Address)
he UAdA tAker to hold tempo ril and I tee the body.
(Undertaker or person haying charge of corpse) (In r,r or*vise di o e o is ow))
)ated 1/..24 19..63... (Signed) ��'
Local Regeritrar
This Permit is sufficient for the Removal (and Interment or emation) of a body to any part of th State bject 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 of CiQ'tkr."1,71...•-../- was i • ,4 196,3
(Interment or Cre
I 1
(Name o: C metery, Crematorium, etc.)
-k
Sect on Lot No. Grave N.
(Signed) - ""_
ii- eratk'd's
Person in charge)Ve/WC-Ctai-
41/
Clil-Ar..\.±.___
Address 6
1,
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 FI:FIY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.