Chambers, W. Wilson Boren MU. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 CERTIFJCATF OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._._._..__........_
5651 Warren Village Lake George
Dist. No County or City
(If city,give street address)
W . Wilson Chambers
Name of deceased Veteran N o
Male Single married widowed, (If veteran, give name of vim)
Sex Color uJhite or divorced (write the word) S in le Date of DDe th.... eore
Jan• 2, 19 61
(
Age 45 Years,...... . Months Days Birthplace Laake z
Cause of Death Lpilepsy
Certificate was signed Hllton I� . tier M.D.
Address ake aeoro.e? 11.7.
Place of Burial (or Removal)e {� pa l ri)neview Cem Vaults .o Qvzeet�sbu y.,N.Y.
(If body Is to be Trine lview, llli efriete7'
Cemetery 1 1 Y Date of Burial J an.43. i ??i...
(If body is to be temporarily held,Lill in apace later)
Thi 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 of the basis tlt -IEREBY GRANT A PERMIT
to ames 136 Warren St. Glens Fal1s,N .Y.
t Underakde) Inter (Address)
the to hold tempora 'y a the body.
(Undert pr or moon having cbareeA corpse) �, �,remove, o snose of[stab how])
cdl as v�f tt 0�
-
Dated ' 19 (Signed) �,l..e. . .�..... ... .. .. .. .. . ..
( ) Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of 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.
ENDORSAIENT OF SEXTON OR PERSON IN CHARGE OF
PRFMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
c
Date ' ?L- Wit/r/-- was- ‘ 1' y
/ (Interment or )
I
(Name of Cemetery, Crematorium, etc.) -
Section 6-7---- --"---‘cc -
Grave No.
(Signed) 7Oflth .)
,
Address /� i- C y _ 7;: -4
":74:
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.