Rooke, Lena Form VB.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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. _Tewa_ Registered No.__--)...-I...
Village
Dist. No.5.0Q1 County Warren or City Glens Fa► .I,s..Hospi.tal
(If elty, give street address)
Name of deceased Lena..D..11aoke Veteran No
(If veteran, give name of War)
Single, married, widowed,
SexE'emale..Color..h.ite....or divorced (write the word)..Mar.r.i<?d Date of 1.Death Mali 31 19..6.7.
Age 71 Years Months Days Birthplace art Edward N.Y'
Cause of Death Pulmsma.rY gdena.
Certificate was signed by...1.7.0.sep1 FI'iJ glad M.D.
Address Fort Edward N,Y.
Place of Burial (or Removal) isawn...Qt eerasbury...Wazr.ex CO... N.Y.
(If body is to be temporarily held,fill in space later)
Cemetery Seelve Date of Burial...sun.e 2 1a7...
(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.Cal1.Vtall FIIXIeX.O. }kale Inca (i\ C,Wilson) . Hudson Falls N.Y.
(Name) (Address)
the....Funeral Di.rec.tor to hold temporarily and I tlux the body.
(Undertaker or person having charge of corpse) (Inter,rikrave,or otherwise dlsoose of[state bow])
Dated June / 19..67. (Signed) ''V LgArZitar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y 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.
INDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date oZ 7;"-Z- r-..� was 19
(Interment or
(Name f aetery, Creme toriva, etc.)
Section Lot No. Grave No.
(Signed),
( son In charge)
1 /
Address (I 6( 4i.
Person in charge must return this Permit tO
the Registrar of his District within SEVEN CO 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 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.