Suprenant, Eleanor NEW YORK STATE DEPARTMENT OF HEALTH
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. (?/ 7/
Registered No.
Town, Village
Dist. NoO/ Co my CO- - -- or City
Name
// / If city, give street address)
Name of deceased ,K �-� �� 2P�-� —�^Veteran
(If veteran,give name of War)
Single, married,widowed, G
Sex p • or divorced (write the word ,�G�x ,e4. Date of Death / a--// 19 /�
Age Q Y nth!' Days/ BirthPlc _ 4--Xy
Cause of Deah 11 .
Certificate was signed by M.D.
Address t o
Place of Burial (or Removal) .. ��, ,___- t-4447 - *-r:
(If body is to be t m o arily , f' 1 in s a e later) �j
Cemetery Date of Burial / 19 7
(If body is to be temporarily-held, fil in space later)
The CERTIFICATE OF DEAT 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 regist ation, have recorded it in my Local Record with the a ove stated Registered Nu bey, and on the b sis thereof I HE -
BY GR , A P IT 1
to CJ _. v • ( ---
�/ (Na e))22.4.--"_,Yedc....‘j
� ddress)
the '"hc G to hold temporarily and the body
(Unlertaker or person h ing charge of corpse) (Intt4oves oth Ise dispose of (state how))
Dated I.a /9 19 -77 (Signed)
Loci Ite stray
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. 6/631 (8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of Interment was 4 - 1 - 1980
(Interment or Cremation)
St. Alphonsus Cemetery
(Name of Cemetery, Crematorium, etc.)
Section Pr1 P St S Lot No. 10 Grave No. 6&7
(Signed) ( _<`-r
(Perso in Charge)
Address 35 Broad St_ , P_0_Bax 600
Glens Falls, NY 12801
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.