Kenney, Mary Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
yr 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. I
Town Registered No.__.._.............._
Saratoga Village T;wr'. of i t,rec:u
Dist. No County or City
a^y F.
e rey (If city, give street address)
Name of deceased Veteran
r Single, married 'widowed, (IF veteran, give name of Wu)
female Hate g. , ' :rdcYred .,
Sex Color or divorced (wnte the word) Date of Death 19
Age �Q Years Months. Days Bi act ..
Cause of Death ,eveorai ascu_Lar ..cc1den- Avt. sed5i�
'vellum T. Simmonds;'R"7-7Ter m.. • •r•,1r,Y.
Certificate was signed by M.D.
Address t Ilarrison Ave.
Place of Burial (or Removal) Pine View Cern. Town of C?'. -:nsbury, N.Y.
(If body is to be temporarily held, fill in space later) Q
Cemetery - '."- Date of Burial fan' i'O,i96 19
(If 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 Ibvik,thereof I HEREBY GRANT A PERMIT-6 Tarr Glens Falls N. Y.
to
rindertaker (Name) inter (Address)
the to hold temporariland the body.
(Undertaker oir„pex�pTh aving charge of corpse) --�eer, remor of d "nose of[state how])
Dated van_ . ,,.,._ 19 (Signed)C.,- t ......, ' t. _<-r_ q,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the state (.abject 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 SEXION OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMEIINTS OR CREMATIONS
ARE MADE
Date r was < C 19 C •
(Interment or`eP( n)
i Cam +"ZL-�- Y�Zii.,.4 'L-.` ,
` (Name of Ceme y, Crematorium, etc.)(
Section 1- Lot No.'s 0 Grave No.
(Signed) � / 1 -r > �/ C-•' (.f
(Pe son in charge) 7Z
Address (7" f, �f L,( •
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 wards
"No person in charge," and FILE PERMIT WITHIN TKREE
(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 ON'FBNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.