Gravelle, Lloyd NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Viltage, 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.
Town, Village Registered No.
Dist. No. County Essex or City Sch.X.Q. ?✓<i
(If city, give street address)
Name of deceased Lloyd E,Qa ,aue1le Veteran WN1 II
(If veteran, give name of War)
Single, marred, widowed, married Jul 4 76
Sex male or divorced (write the word) Date of Death Y 19
Age 53 Years Months Days Birthplace
Cause of Death Acute Coronary Occlusion
Certificate was signed by Dr. Phillip Sawyer M.D.
Address Schroon Lake, NY 12870
Place of Burial (or Removal) Tn of Queensbury,t NY
(If body is to be tem prarily,held,;ii[I in space later)
Cemetery FPineview Date of Burial July 8 19 76
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with the above stated Registered Numbe -, and on the basis thereof I HEREBY GRANT A
PERMIT
to Carleton Funeral Home, Inc. ud n Falls, NY
(Name) (Attar ss)
the Funeral Director to hold temporarily inter the body
(Undertaker o5person having charge of copse) nt� e, remov , or otherwt e drsi7 eof tate how))
Dated July r 19 C (Signed) T , �;i .-J f./ /
Local egigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of th State(-subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. ) is required.
F'O11.M vs. 61. (RI V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No.. 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 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 required, under
penalty, to report violations thereof.