Orcutt, Mary NCW TVKK JIAIC UtrAKIMCNI car I•ICALiri
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. 6
Registered No.
4 24 Town, Village
Dist. No. 5 CountySARAT OGA or City V_ILAE___OF___BQ_.____GLENS.._FALLS
If city, give street address)
Name of deceased MARY ALTHEA ORCUTT Veteran NO
(If veteran,give name of War)
FEMALE Single, married,widowed,
Sex or divorced (write the word) WIDOWED Date of Death _1.2/6/79 19
Age 97 Years Months Days Birthplace N•Y •
Cause of Death MYOCARDITIS
Certificate was signed by DR. MCKEE M.D.
Address SO. GLENS FALLS, N.Y .
Place of Burial (or Removal) FRIENDS CEMEy RY QUEENSBURY N.Y .
(If body is to be temporarily held, fill in space later)
Cemetery QUEENSBURY Date of BurialLit't4_ _ 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
to DONALD CLARK 136 MAIN ST . SO. GLENS FALLS, N.
(Name) (Address)
the DONALD CLARK to hold temporarily/ nd . I TER the body
(Upl rtcer�, r_��person having charge of corpse) I (I e ispo of (state how))
Dated ]]. �/�0/ 19 (Signed)
Local 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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was Li 61-"-C-4?1 19 7
(Interment or Cremation)
(Name of Cemetery, Cremytorium, etc.)
Section - . Lot No. Grave No.
4/7(Signed)
(Person in C,h6rge)
Address / i(fC-1`t- vx " `., -0 �.'i .. sA-7
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.