Trombley, Mariah NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
aSeP 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.
T�
/
Dist. No. / 0 / County - o City
^��, f city, gives et address)
Name of deceased �L / Veter
(If veteran,give name of War)
3.--- Single, married,widowed,
Sex or divorced (write the word) 11 Date of Deep19//r
Age Years Mon s __--_./__0 Da B' ce
Cause of Death 71—jWLQ--'t
Certificate was signed by " M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held, fill in spa t -
Cemetery .Q._` a e of Burial -L�-z-e 19_c/.
(If body is to be temporarily held, fill in pace later) / /
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after'carefu 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 D.'
BY GRANT PERMIT
to — — ��. - a 1r
(Name) (Address) �
the to hold tempor rily and z the by
(Unlertak person h ving harge of corps • - iur e, or . e dis.•-• of how
Dated �/ 19 `� (Signed)
1 Local Registrar
This Permit is suffi • nt for the Removal (and Interment or Cremation) of a body to any part of the State (subject to 1 al
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) (6A2.130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of Interment was 5-7- 197
(Interment or Cremation)
St. Al phonsiis
(Name of Cemetery, Crematorium, etc.)
Section ,= r Lot No. 2? Grave No.
(Signed) J
(Person in Charge)
Address 35 Broad 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.