Trombly, Katherine PICVII IVOTER JIRIC LiCrAKI POIC/4 I v."r IICAL I 11
OFFICIAL BURIAL (OR REMOVAL) PERMIT
friSF' 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.
-----
Village
Dist. No. 74 i County la,"4,..t .-- , ,
or City
Town I ity, give 7)
1°,47e—
Name of deceased 7
/1/7/1- - / .:.: erlA1 ,1 - Veteran
eet ad dr
(If veteran,give name of War)
Single, married,widowed,
Sex /re-/dig le or divorced (write the word) 1.4/ 2/411•14t CI Date of Death VI/Ate ? 1977.
Age 7F Years ,7 Months Days Birthplace Ve/r IsI 0 itt%-
Cause of Death fihei./Aliri& /leg"(T A'cease_
Certificate was signed by vo/e?..n___/72f.... P4 ifr r 5 M.D.
Address g2____A4x.A7.4._f_.....5 7- • 3,744 7064
Place of of Burial (or Removal) 144°57 -4,(K,5 /'----€1/is N-
., re '(.../
(If body is to be temporarllyield, fill ip„space later)
Cemetery 6/ -A A-P./7t-1--5- Date of Burial 115.4 I" 1977
(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 GRANPERMIT /
to VA -V -/lVir" /
,./ (;
ameL^......_ ... e ss)
the/ 'CI'f#f a( • >raw e to hold temporarily and the body
(Unle .er orpeson haVng charge of corp, i Int r ove,eh rwise d of Citaie how))
Dated (Signed
V VA/ (Signed .-'?i i
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 Interment was 6 - 11 1979
(Interment or Cremation)
St. Aiphonsus Cemetery
(Name of Cemetery, Crematorium, etc.)
Section I Lot No. A Grave No. 5
(Signed) ���//�, �1
(PeYson in Charge)
Address 35 Rr(ia i St. Glens Falls, N.Y.
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.