Brock, Paul NEW YORK STATE DEPARTMEN I' OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
:SW" This Permit can be signed only by the Local Registrar (Deput, bubregistrar) 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. k
Town, Village Registered No.
Dist. No.. 5601 County Warren or City Glens Falls Hospital
(If city, give street address)
Name of deceased Paul E Brock Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex MaJ,e or divorced (write the word) married Date of Death Feb. 9 1967
Age 63 Year 2 Months 4 Days Birthplace Bensen Vermont
Cause of-Death --)-e-e. .4%'mac.`-`-,42_, 7
Certificate was signed by Joseph. Feintgc2l-d M.D.
Address_Ea5..Street,.Fort-.Edward N.Y.
Place of Burial (or Removal)...,.shwn..Qu eflS12u,rY Warren) Co. N,Y.
(If body is to be temporarily held, fill in space later)
Cemetery Pineview , Date of Burial Fed?. 13 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
toCar.l tpra..kkulera.,] litale...XxmAIAr.C,Wilson) . Hudson Falls N.Y.
(Name) (Address)
thE.unexal. Direc:Lox to hold temporarily and Inter the body
(Undertaker or person having charge of corpse) Cyder,remove, ore erwise disp ae of [state how])
Dated February i t" 1f'7 (Signed).. 1..i.gr-- > .Z
i R gistrar
This Permit is sufficient for the Removal (and Interment or Cremation f 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. 6/631 (3A2-3231
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
Or PREMISES ON WHICH INTERMENTS QR
CREMATIONS ARC MADE
to 0 • 4 10_�
(Interment or n)
/,,,....„-_ ,.,4".....,-c----(.... 4----,7 - ..—:-..i_ _ ._�:�- (Name 0Cemetery, Crematorium, etc.)
L 21e04
SectiiPfl .__ Lot 6;- Gr4Ye 10,3—
`7`
(Signect) , ezz--11,-i' ,_( ----C--z 6',?; (-/ 2
(Persg71 SR 0(ya(e)
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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.