Buckley, Francis NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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.
T VillageRegistered No. 146
198 Albany own, Albany
Dist. No. County or City
(If city, give street address)
Name of decease�'rancis J.. Buckley Veteran WW 2
(If veteran, give name of War)
Male Single, married, widowed, Married 4/26 78
Sex ,... , or divorced (write the word) Date of Death 19
Age 60 Years .Months Days Birthplace New York
Cause of Death Bilateral, bronchopneumonia
Certificate was signed by C, Yanofsky M.D.
Address VA Hospital, 113 Holland Ave. , Albany, New York 12208
Place of Burial (or Removal Queensbury, New York
(If body is 44ieelteemnorrarrily he d, (ill.in space later)
Cemetery l5 Date of Burial 4/2ft9 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
to .Carleton...Funeral Home, Inc, 68 Main Street,Hudson Falls, New York
(Name) (Address)
the Undertaker to hold temporarily and Inter the body
(Undertaker or person having charge of corpse) inter, ,gve or otherwise pose of (state how))
Dated 412.619 78p (Signed) C (.t . :(ocal L.
Local Reg
L igtr
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (su ct 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. ((INN. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of '`W°' -4/ was � � 19 " C
(Interment or Cremation
1:12
(Name of Cemetery,
Sects�io5f"`} "`��'Lt'�Lot No._,=�Grave No.
(Signed) ��t
(Person in Charge)
Address / 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 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.