Dietz, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1 This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, 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. / ? ,
R
�� of -'1ns a1 N s NY
Dist. No. 5601 County `Marren or City
(If city, give street address)
Name of deceased ''7i17.iam ,`. T)ietae Veteran "es ='ocean T''ar.
(If veteran, give name of War)
�1P Single, married, widowed, Married March 18
Sex or divorced (write the word) Date of Deatht 1978
Age '4-7 Yearsj // onths Days Birthplace New York
Cause of Death Lt.IS.Y"`i.L'. .....! ... 4,.J'//)//)_04).,'ail n� i4/11 "
Certificate was signed by /! "i -hard `-IQc.aI M.D.
Address 352 Main Str-'et, ''udson rails, NY
Place of Burial (or Removal Tn of Qucensbury, N`'
(If body is to be tempgr tl}Iye Jeld� i11 inn pa�cee later) March 21 78
Cemetery P Y Date of Burial 19
(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 4ppearing 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 Number, and on the basis thereof I HEREBY GRANT A
PERMIT 68 Main udson Falls NY
to Carleton �='uneraZ l-'ome Inc. Street, ;
Funeral Director interAddressS
the to hold temporarily and the body
Dated(UndertaMker halve charge loof corpse) (Inter, ve, o otherw se of (state how))
0 (Signed)
oc This Permit is sufficient for the Removal (and Interment or Cremation)of a body t part of the S at 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) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of (7C41164-"Iwas 519
(Interment or Cremation)
(Name of Cemetery,
//lf
Section Lot No. /fe Grave No. c .
(Si ed
(Person in Charge)
Address 44 / - '
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 UNDJ,-
TAKER MUST SIGN ABOVE STATEMENT, write acros
face of the Permit the words "No person in charge,".. .,
FILE PERMIT WITHIN THREE (3) DAYS with the Regi r
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.