Roman, Frank NEW YORK STATE DEPARTMENT OF HEALTUU
OFFICIAL BURIAL (OR REMOVAL) PERMIT
0 ' 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.
11
Town, Villa e
Registered No. �
Dist. No.. 5601 County Ware or City Glens Falls Hospital
(If city, give street address)
Name of deceased Frank Rom Veteran No
(If veteran, give name of War)
Single, married, widowed, Married
Sex..._Male for divorced (write the word) Date of Death Noy. 25 1965
Age 64 Years. 1 Months 10 Days Birthplace WQrQham Mass
Cause of-Death Ventricular Fibrilation and Cardiac Coyest
Certificate was signecs.ax' 1 .Betz M.D.
Address_9_..Sherman..Aue,.Gl ehS..FA11S..,TLY.a.
Place of Burial (or Removal) West.Glens._.Falls.._N.Y.
(If body is to be temporarily held, fill in space later)
Cemetery West..Glens..:fr.alls- Date of Burial Nov....2_9 1945.._
(if body is to be temporarily held, fill in spice Ia(er)
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 Carleton Funeral Home In,.c...- (A.C,Wi1, cn) . H gISPA mils Na.
uneral Director (Name) Inte (Address) the body
to hold temporarily and
(Undertaker or person having charge of corpse) (I ove, or otherwise spose of Ist ow])
Dated_. I.OV......26. 19.b..5— (Signed)
Local -gis rar
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.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
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Date o$` 1 t//1' .was a:Z i G> 19
(Interment o // / ,
-/e6 -- ,6,-j-
1L4Y ' L
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(Name of Cemetery"Crematorium, etc.)
Section_- Lot No. Grave No
(signed)7-21K--
L,�...r�'� _ �‘��`.- ...�
(Person in Charge)
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Address G • �-' `
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✓/ ' X ,. 7/
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
will be enforced. Local Registrars are required, under penalty,
to report violations thereof.