Potter, Floyd 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 death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CR-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Villa e Registered No...3 0-
Dist. No. 5601 County Warren or City ....1ena..Ealla..iiaspi.tal
(If city, give street address)
Name of deceased Fltoyd Potter Veteran Yes
(If veteran, give name of War)
Single, married, widowed,
Sex Male or divorced (write the word) Sjnglt Date of Death October 25 1967
Age 67 Years. Months Days Birthplace Twn Queensbury Warren Co
Cause of-Death Acute Myocar.ljal...Infaxction N.Y.
Certificate was signed by Richard Hogain M.D,
Address.Uppex.Maim..$treet.iiudson..Ealls...N..Y..
Place of Burial (or Removal)..I D.,.Queelaslaur.y H1a.rren...C.o....N..Y...
(If body is to be temporarily held, fill in space later)
Cemetery West.GLens-.Falls .Date of Burial... -7 >> 2. 19 67
Of 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
tear-letlon.-Funeral.•-Home--Zno,..(E.W,WiLsoa). ...thudsarl--Falls-..N.Y.*
(Name) (Address)
thFLuleral Di.rec1L2r to hold temporarily
'-aannndry`,,nteInter the body
(Undertakerb or person having charge of corpse) ��-a `r'. Oe otherwise dispose of [state how])
Dated�ctober 27 1967 (Signed)....�t. 14-1
Lo Registrar
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, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of _! was ��C-- y 6 19 7
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.) J
Section____ Lot No. Grave No.
(Signed)./ G�2 / i_ r_._. -7. I —
(Person in Charge)
Address /'' j -!
r/f �
7 0-27. , ?
Person in charge must return this Permit to the Registr
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.