Knowlton, Leon NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ee 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No
Washington Town, Vil4ve Falls
Dist. No. -- _ County or City
(If city, give street address)
Name of deceased Leon B. Knowlton Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex Male . or divorced (write the word) Widowed Date of Death October 10 19 64
Age 7It Years. Nionth_s Days Birthplace Stony Creek,, NY
Cause of Death Acute Coronary- Thrombosis
Certificate was signed by Hobert Hoaer M.D.
Address Hudson Falls NY
Place of Burial (or Removal) Town Queensburyi Warren County New York
(If body is to be temporarily held, fill in space later)
Cemetery I t-.---merman .Date of Burial October 13 19 64
Of 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
toCarlet9m Ft1ilg ' 1 HomgG.. Inc. LE„W,Wilson) Hudson Falls, New York
the Undertaker (Name) (Address)inter to hold temporaril id the body
U de taker o rson having charge of come) i , (Inter,remove, oq otbe ise dispose of s how))
Dated de oter 5 19' (Signed) /11// �.
Local Regist r /
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, 6.) is required.
Form VS. 61. (Rev, 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
� [f
Date c ` wa �� 19
(Interment or remation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.—____
(Signed) _ ��
(Person 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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict 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
win be enforced. Local Registrars are required, under penalty,
to report violations thereof.