Mooney, J Dudley NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 dtath occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village
Registered No.
Dist. No. ._....__:4,601 County Sady or City SGYis y
(if city, give street address)
Name of deceased J,,..Dudley..Moomey Veteran no
(If veteran, give name of War)
Single, married, widowed,
Sex male or divorced (write the word) married Date of Death Dec 21? 1965 19
Age 69 Years Months Days Birthplace Lake..PJ.sced..NY
Cause of-Death bilateral bronchopneumonia
Certificate was signed by Dr. Kehoe M.D. M.D.
Address 413 Mohawk Ave. Scotia NY
Place of Burial (or Removal) Town_ of Queensbury N.Y
(If body is to be tentyziay.. 11,17, space later)
;,,-.C;W:C "ry Pine View 4....,.�..�: ---,----,,,,,„_...Date of Burial.........De.e., 3r.1965 19
(If body is to he temporarily held, fill In space later) "'o-.__,.
The Certificate of Death containing the above stated particulars, having been i,: s Itei 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 E1lio_F neraLRQ P 846 State St, — Schdy NY
(Name) (Address)
the undertaker to hold temporarily and i ter the body
(Undertaker or person having charge of corpse) 7 ...f (I remove, or�oth�y ise spose o rstate hq+G )
Dated Dee..22,...19.65. 19 (Signed)' :.'..: _Ct11:h!L.L�":1��z. '.2�1- , r .#
Local Registrar
This Permit is sufficient for the Removal (and Interment or , mation) 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 PIERSON IN CHARGE
OF PREMISES ON WHICH INITERMENTS qR
CREMATIONS ARE ?MADE
:t
Date was 19_ +' v
(Interment.er ion) ,
(Name of Cemetery, Crematt mum, etc.)
Section_., ' -'' Lot No. Grave No.____
•
,,�..
(Signe.,�
(Person in Char*e)
Address «' G G 6 ----
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 witi'i the Registrar of Dis-
trict in which cemetery is located.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return permits are liable to
a penalty of NOT LESS THAN FIVE L OLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIFTT OFFENSE. The law
will be enforced. Local Registrars are -required, under penalty,
to report violations thereof.