Potter, Mildred 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.
Town, Village
Dist. No. 1701 County Fulton or City Gloversville
If city, give street address)
Name of deceased Mildred Potter Veteran no
(If veteran, give name of War)
Female Single, married,widowed, married l
Sex or divorced (write the word) Date of Death 3-13— 19 77
Age 72 Years Months Days Birthplace NY
Cause of Death Cerebral _Hemorrhage
Certificate was signed by Hans--.Po-llak M.D.
Address Gloversville, NY 72078
Place of Burial (or Removal) Glens____Fa1 1 s_ -NY
(If body is to be temporarily held, fill in space later)
Cemetery West.__Glen___Falls Leta. Date of Burial 3—i6— 19-17_
(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 examination,
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 HERE-
BY GRANT A PERMIT
to Hollenbeck Funeral Home Gloversville, New York 12078
(Name) (Address)
the Charles Blomquist to hold temporarily and inter the body
(Unlertaker or person avin ge of corpse„).„ (Inter, ove, or erw' e ' pose tate how))
Dated 19_// (Signed) ? 4- �l��L.(
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 No. 62) is required.
FORM VS. 61. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
c4aj111
Date of was 19 �7
(Interment or Cremation)
(Name of Cemeteq, Creocrterle
Section Lot No. Grave No.
(Signed) (idier—el--rt"
(Person in Charge)
Address "Pee'
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
UNDERTAKER 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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.