Anderson, Earl 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. v7
Registered No. . -.-.l-r_
f� � Town, Village /
Dist. No. OS‘ County 6L.9 _. . or City
------ --- --- - -
� f� If city, give street ad s) '
Name of deceased f`-�'-`"�'1 -. /' a,,,....4„.„. Veteran
y (If veter ,give name of War)
Single, married,widowed,
Sex or divorced (write the word) Date of eath a.6 19- �
Age _ _- _ _ Years Months , Days Birthplace
Cause of Death — /vr��` -� . ...
Certificate was signed by _-.. M.D.
Address 0 l tr .4- .
Place of Burial (or Rem val .. _ ���A... ._. ,t.-
c� 7
(If body is to b: :t pora d, ill ' space later) O
Cemetery.....y, Date of Burial 1 19__-7i
(If body is to . emporarily h , fill in space later)
The CERTIFICATE OF D ATH containing the above stated particulars, having been presented to me, ter areful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I hav accepted the same
for registr on, have rec ded it in my Local Record with the)above stated Registered Number, and on the sis thereof I HERE-
BY GRAMIT l l�iri
toC J J•
(N e) (Address)
the �){/ m to hold temporarily and the body
(Unlertaker o pe having charge of corpse) (Inter, r , or erwi e isp se of (state how))
Dated .r2 19_.7. (Signed) / i
Local Regist r 1rv)
This Permit is sufficien for the Removal (and Interment or Cremation) of a body to any part f the State (abject 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) )8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of Interment was ,''LuEust 25 197?
(Interment or Cremation)
St . .,1phonsus
(Name of Cemetery, Crematorium, etc.)
Section ;pp-— Lot No. ; Grave No.
(Signed)
(Person in Charge)
Address 35 Broad St. Gl ens Falls, NY
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.