King, Charles 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. No,.9 v,' / County Schenectady or City Schenectady
(If city, give street address)
Name of deceased CHAR L ES F , K I NG, J r . Veteran — — — —
(If veteran, give name of War)
Male Single, married, widowed, Si l e Sept 3 6 7
Sexor divorced (write the word) 9 Date of Death P a. . 19
Age 19 Years. Months Days Birthplace........Q.J..2..n 5 F a.1.J..5., N. Y.
Cause of-Death Extensive internal injuries
Certificate was signed by John C. Sherman, Medical Examiner M.D.
Address 22 Roslyn Drive, Glenvi I le, N. Y.
Place of Burial (or Removal) Town of. 'Queens b u r y_, N. Y.
(If body is to be temporaril ad, fill pace later)
Cemetery n¢ ¢w , Date of Burial S e p t . 4 1967
Of body is to be temporarily held, RII 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 136 Warren S t . '
to Potter Funeral Service Glens Falls, N. Y.
undertaker
(Address)
the to hold temporarily-and inter the body
(Undertaker or person having charge of corpse (Inter,rem e,or otherwise d' po of [statp,how])
Dated S Q.p.t...........4.. 19 6 (Signed) -7--t-.:�,,/ ..... 4 1
t j Vocal 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, 82) is required.
Form VS. 61. (Rev. 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS 9R
CREMATIONS ARE MADE
Date wa 15412
(interment or
'm eCrmatorium etc.)( e of Cm,�tty,Cj
l 2.sy, f�f
L'
Section Lot Nt /A Grave No.
(Signed) ._
(Person in Charge)
Address
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 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.