LaValley, Alfred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ler 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. `3l 1
Registered o. /,I
���/ 7 Town, Village
/� -s
Dist. No. County �� or City dg
If city, give street address)
Name of deceased Veteran
,..0_1/ (If veteran, give name of War)
Q Single, married,widowed, (�
Se. A �/a or divorced (write the word) _ 0.Ailt.lL Date of Death 7/Z6 19.7?�.
Age 7o Years Months .. _ Da Bi hplace v
Cause of Death .. -
Certificate was Y signed b M.D.
g Address /p�a `-1 -r—>'
Place of Burial (or Removal) -_ ._- ....
(If body is to b� ,,.orar' he 1, f' l i 'pa e later)
Cemetery_ Date of Burial /�' ' 19.7,1..
(If body is to b`•.emporarily held fill in space later)
The CERTIFICATE OF DE H containing the above stated particulars, having been presented to me, ate careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regi r ion, have recorded it in y Local Recor with the above stated Registers umber, and 6° e b is thereof E-
BY GR A P IT
to - V I .
J/ (N me) (Ad. ess)
the . _ _ __ _ __ .. ... _. _. ... to hold temporarily and the body
(Unlertaker r person hfvin char a of corpse) (Inter, ove,S• othe v se di ose of (state how))
Dated / // 19.7C (Signed) d .`_..
Local Reg' rar
This Permit is sufficient for the Removal'(and Interment or Cremation) of a body to any pa of the ate (su ct to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is equired.
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 July 13 19 79
(Interment or Cremation)
St. Alphonsus
(Name of Cemetery, Crematorium, etc.)
Section IT — L Lot No. 18 Grave No. 3
(Signed)
(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.