Collette Sr., Theodore NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qgr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. No. ...'415,03 County S.chezleetad.y or City EJ..1is. HosPitai
(If city, gie�Ie t address)
Name of deceased Theodore H. Collette Sr Veteran
Sing , (If veteran, give name of War)
Sex Male or dilvorcedr((write the word) Married Date of Deathjanuary 4 19 78
Age j 7 Years .Months Days Birthplace Connecticut
Cause of Death Carcinoma of the lung
Certificate was signed by John W. Jaski, M. D. M.D
Address 1101 Nott St. , Schenectady
Place of Burial (or Removal) 33ueensbury New York
(If body is to be temporarily_field, fill ins aLce later)
Cemetery Fineview Cemetery Date of Burial January 7 19 78
(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 Number, and on the basis thereof I HEREBY GRANT A
PERMIT 82 Broadway, Ft. Edward NYto M• B• Kilmer Funeral Home
(Name) (Address)
the undertaker to hold temporarily and int.ar the body
(Undertaker or person flaying charge of corpse) Inter, remove, otherwise dispose of tate how))
Dated ..d.arkuar.y $ 1976 (Signed) r : e.... .. ... ... ..J1k
Loc 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) (9A2-205) 91
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was 19
(Interment or
(Name of Cemetery, icltniatorium, etc.)
Section z.Atf,' Lot No. d f Grave No.
(Signed) )4'11
(Person in Charge)
Address ^% 7 �` )Z
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.