Southard, Walter Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W 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.__.?........... ......._..Wife
Dist. No 4562 County Saratoza Moreau
(If"' give street address)
Walter Henry Southard
Name of deceased Veteran
male white Single, married, widowed, (If veteran' give name of War)
Sex Color or divorced (wnte the word) married Date of Death Jan. 29 19 63
Age Years Months Days Birthplace
Cause of Death Coronary Thrombosip
Certificate was signed )4y a�1`•i•MeKee M.D.
Address SO' �1en8 ' �.s,l . .
Place of Burial (or Removal) Pine View Cem. Town of Queerlsbury, N.Y•
(If body is to be temporarily ily held,fill in space later)
Cemetery t View
Date of Burial Feb....]. 19 63
(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 Regan & fenny Inc. Calens...1.1111a,N...::.
(Name) (Address)
the uncte.rtalcer to hold temporarily nd...,.inter the body.
(Undertaker or person having charge of corpse) ( ore,o of rwise Minos('of(state how])
Dated J4l1n...31. 19 63 (Signed)
Local Regtstrar
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 INTERMENTS OR CREMATIONS
ARE MADE
Date was 19,t�
(Interment or C mati
C
(Name of Cemetery, Crematorium, etc.)
4 -
ction Lot No Grave No.
(Signed) /� -'",%14,/1/;':7„, /� 6y��J`( '`
/ (Person in charge)
Addres144 FV----q7/3/1-01---"..-44 _, .„....6/_/:
Person in charge Deist 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,
RENT, 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 OPTT.NSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.