Sacia, LaVerne NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ILA 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. f
, ,_ Falls
Dist. No. 72o County Washington 6Q Village Hudson
If city, give street address)
Name of deceased LaVerne W Saci a Veteran n_o
(If veteran, give name of War)
Single, married,widowed,
Sex male or divorced (write the word) sink rl_e Date of Death 12 /11 19.-77
Age 71 Years Months Days Birthplace Onean` ►-4, NY
Cause of Death Cardio Respitatory Arrest
Certificate was signed by Richard P. Leach, M.D. M.D.
Address 19 Pine St; Glens Falls , NY
Place of Burial (or Removal) T_n___of ",ueens-burtiv
(If body is to be temporarily held, fill in space later)
Cemetery Pineview Date of Burial 12/13 19 77
(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 Carleton .Funeral Home, Inc . Hudson Falls, N Y
(Name) (Address)
the Funeral for.e to hold temporarily a iI t_ the body
(Unlerb4uut'ionihr,ing charge of corpspl r, remove, or ./1 i c•�y: how))
Dated UL CC ' 19 (Signed) . �v ' ?`-o _ —'
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
Date of Interment was 12/13/77) 19
(Interment or Cremation)
Pine View
(Name of Cemetery, Crematorium, etc.)
Wah Tah Wah Plot
Section 27 Lot No. 9J111 Grave No. 1
(Signed) a
(Person in Charge)
Address / J �
V
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.