Pruyn, Sanuel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qr 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. l5--��
Registered No.
Dist. No. 5601 County Warren r City Village City of Glens Falls
If city, give street address)
Name of deceased S.amuel._.Px' Y s --•LlyTl Veteran xx�:. _._
(If veteran, give name of War)
Single, married,widowed,
Sex Male or divorced (write the word) __1611.dawe-d Date of Death ._.Qct._.-26 19.7_t;_-
Age 8? Years Months Days Birthplace New York State
Cause of Death Congestive Heart Failure
Certificate was signed by James Morrissey M.D.
Address Glens Falls, N.Y.
Place of Burial (or Removal) Town of Quo. -z bury-,--_.I`Ia.
(If body is to be temporarily held, fill in space later)
Cemetery Dine View Cemetery Date of Burial October 28 19 $__
(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
'Regan egan & Denny, Inc. Quaker Rd. ,Glens Falls, N.Y.
(Name) (Address)
the Undertaker to hold temporarily and Inter the body
(Unlertaker or p son having charge of corpse (I er r ,.emov or o e wis dispose of (state how))
Dated........_../��. 2.-1 19-. .LY (Signed)
Local gistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the c 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 of
W:< 19 7"
(Interment or Ceemation)--_._
tee. fi%�zt
(Name of Cemetery, . -
14114/4,14
Section `%`"t Lot No. Grave No. }�
(Signed)
/ (Person in Charge)
Address F / ' e
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.