Hayes, Gordon 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. 4
Registered No
Town, Viltalpf Kingsbury
Dist. No.. 5762 County Washington D.Sityc
(If city, give street address)
Name of deceased Go.rd.oxi...It....E.a y.e Veteran No
(If veteran, give name of \gar)
Male Single, married, widowed, Married October 11, 67
Sex or divorced (write the word) Date of Death 19
Age 7$ Years Months Days Birthplace W?11 S a N.Y.
Cause of-DeathArteriosclerotic Heart Disease
Certificate was signed by C . V. Latimer M.D.
Address Hudson Falls, N:T.
Place of Burial (or Removal)...1.S.Wl...0.f,.. 4ll.e.ensbury, N.Y .
(If body is to bpi m orari}yr heldhe fill in space later)
Cemetery rr �111 VV Date of Burial October 1la , 1967
(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
G1ens Falls , N .Y.
to Regan & Denny, Inc .
undertaker (Name) (A•• ess)
the to hold temporar' •,1146 the body
nd rtalcer or person having charge of cor (Inter,rem ve, o `dispose nowll of ate
Dated uto er 1 19 °t (Signed)
epu y Local 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 Na, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS CAR
CREMATIONS ARE MADE
Date of " ' was / ! G=r� / 19
(Interment or G.mmahett)
.�fjz-.._.. _..:�/ -�._�_ L.-.•.''c-"1-vte-- C.�-cam-��
(Name of Cemetery, Crematorium, etc.)
Section_ 3 ? '/ Lot No. -2,5 LY Grave No._2
(Signed) _ L1�1
(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.