Van Vranklen, Walter Form VB.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 F
DEATH, LEGIBLY WRITTEN IN yURABLE BLACK INK. Tewn- Registered No. . .......Y
f village
Dist. No County...,.i xa&—' .a... or-Sits ....-)V al te4....
*� � (If city, give street address)
Name of deceased....Ilt1.�...�..,... .w.y.,k,k6 , . -,.. Veteran 6 0
Single, married, widowed, (ti ��e�.n �a;�� name of War)
Sex.tl.1} E...Cotor..��.H.Ltgor divorced (wnte the word)..rn(d.4Aue Date of DY a IC;/(�!. - 19.6E
Age .,`�..Year Months .,,,....Da s Birthplace
.
Cause of Death � u* A�I A `- -
Certificate was signed by tat.> ta- .a., �i;1:... . .is+ .c&..• c../.4. �} M.D.
Address /4 '24 ,,. '..Z1-2 .o ' n,-.�.`�C &
Place of Burial (or Removal) --'-(.,i..4.,o ,,.AZ.A / -
(If body 1s to be temporarily heic];_SI1 in spacelater)
Cemetery YJ. >.. s:. z.... .S„Q.c.{).... Date of Burial 7 19 6
(If body is to be temporarily held,fill in space later)
Thn 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
e basis t o I HEREBY GRANT A PERMIT,
.., � G � w IQ Y.&
1 ...6.e11 'r �ri ^ (Address).. �./- . .. •.
the +....... to old tem oranl and the body.
g1i..erta r or De n hazing charge/of corpse) - _(I r, •.•ove,". 3 .isnose of[state how])
Dated....... .� � 191��. (Signed) s, r
This Permit is sufficient for the Removal xe�itras
(and Interment or Cremation) of a body to any part o�V if It1��/St�i�a3a (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 of . was 19
(Interment or Cremation)
•
L^" (Name of Cemetery, Crematorium, etc.)
Section Lot No. 7 ,(a Grave No. ,
(Signed) r'! •c•:!' (,•te '77 ° ((
(Person in charge)
Address
Person in charge mist 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,
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.
VAN VRANKEN Lot No. 1-B
kddress 220 Main S t. , So . Glens Falls, N.Y. Section No.
)wner Walter Van Vranken Plot New Kenesaw
)ate 11/15/58
Approx. 100 Superficial ft. @ $1.30 per sq. ft = $130.00
,ocation Bounded on s/w by Chepontuc Ave.
corner Posts
Zemarks
)eed No. (and changes) 728
'ayment Record Paid in full 11/15/5 8
Form No. 01
Record of Interments
ts
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VAN VRANIN, Walter F. ( LF
Age: 55
Cause: Coronary Thrombosis
Lot Owner: 1 Tal ter Van Vranken
Lot # 1 B, New Kenesaw Plot
Grave # 3
Case: Concrete
Died: 9/b/66
Interred 9/7/66
Undertaker:
Regan