Jessie, James NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gAr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. No. / � County Franklin or City Altamont
(If city, give street address)
Mr. James Roy Jessie No
Name of deceased Veteran
• (If veteran, give name of War)
Male Single, married, widowed, Widowed May1 Sex or divorced (write the word) Date of Death9..1 19 ..279...
Age 7° Years Months Days Birthplace Tupper Lake, NY
Cause of Death Metastatic Carcinoma
Certificate was signed b Dr. Gordon Norman M.D.
Address 5 . tetson Road, Tupper Lake, NY 12986
Place of Burial (or Removal Town of Queensbury, Glens Falls , NY
(If body is to be emporar 1 ,he d, iil1 in s ace later)
Cemetery Pine `View Csm?Iery Date of Burial May 21, 19...79
(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 registra•
Lion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to Marcel V. Richer 29 Park St. , Tupper Lake, NY
(Name) (Address)
the Funeral Director to hold temporarily and Inter the body
(Undertaker_grpersoonhaving charge of cor se) (Inter r ove, or °theitse dis ose of (vote how)) ,
Dated may 21 , 19 ....7v (Signed) .� e+l w (... � �7C-tJ
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 corner, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
.�.1 y IGLU / 9 q
Date of ' was j.
(Interment or Crun.,:... --J
// (Name of Cemetery, C c.
Section Lot No. —31/9 Grave No.
...... P"'► vy--'�L.C.
(Signed)
(Person in Charge)
Address ce,
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 UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.