Coulter, Glenn NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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. 3 77
,01 Warren Town, Village Cit of Glens Falls
Dist. No. County or City `�
If city., give street address)
Name of deceased Glenn B. Coulter Veteran ' o
(If veteran, give name of War)
Male Single, married,widowed, M_ rri e d 21
Sex or divorced (write the word) Date of Death July 1976
Age 73 Years Months Days Birthplace -'-- " . 4 4
Cause of Death Ventricular Fibrillation
Certificate was signed by Robert A. Reid M.D.
Address 8 Harrison Ave. ,Glens Ells, N.Y.
Place of Burial (or Removal) Town of Queensbury, N.Y
(If body is to be temporarily held, fill in space later)
'Cemetery Pixie__View__Genie_t_ery Date of Burial__._thu,7.y_._2.4 1978__
(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 Regan & Denny,Inc. Quaker Rd. ,Glens Falls, N.Y.
(Name) (Address)
the Undertaker to hold temporarily and Inter the body
(Unle ker o person having charge of corpse) ter, Kemofor of erwise dispose of (state how))
Dated . _- 19_7 j (Signed) ...._i 4__,.—_
cal Registrar i
This P mit is,sufficient for the Removal (and Interment or Cremation) of a body to.any part of the tate'(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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date // ' 1971
(Interment or JOrentatio
(Name of Cemetery, Crematorium, etc.)
Section Lot No. 3 Grave No. /
(Signed) `-
(Person in Charge)
.&‘j
Address � �
er
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.