Fontaine, Adrien NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir' 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.
Town, Vi Registered No. 562
Dist. No 198 County Albany or City �- Holland Avenue, Albany,New York
(If city, give street address)
Name of deceased Adrien B. Fontaine Veteran WW II
(If veteran, give name of War)
Male Single, married, widowed, Married
Sex or divorced (write the word) Date of Death 12/13 1966
Age 59 Years Months Days Birthplace Canada
Cause of-Death Bronchogenic carcinoma, right lungs primary, with metastases
Certificate was signed by Anthony Pagliara M.D.
Address VA Hospital, Albany, New York
Place of Burial (or Removal) Town of.Queensbury,t New York
(If body is to be tgtpp�rgril�4eld. fill in space later)
Cemetery t L C lew Date of Burial 12L1, i 19 66
(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 basis thereof I HEREBY GRANT A PERMIT
to Regan and Denny Funeral Home Inc. Glens Falls, New York
Undeftli der (Address)
Inter to hold temporarily and the body
(Undertaker or person having charge of corpse) ; (Ibte)r,remoee,or otherwise dispose of [state howl)
Dated 12/.14 19 66 (Signed)-__„ `- , 1 4,, ;j .:
Local Regtbtrai.
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, 82) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 7--%/1- s>t-: / was. 19_ - -
(Interment or C.,cjaii paw)
(Name of Cemete
ry, Crematorium, etc.)
Section_ • . -71. .. Lot No. Grave No. '_
(Signed) ./ :L ., 1 ' }t`'y` G4e7-2
(Person in arge)
7
. _lam'^
Address i y
f
r-A-----'(_. '
Person in charge must returh 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.