Hladik, Janet 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.
Registered No. SS 6
Dist. No. 5601 County Warren or City Town, Village City of Glens Falls
Janet M. Hladik If city, giveO street address)
Name of deceased Veteran N
(If veteran, give name of War)
Female Single, married,widowed, Married Oct.Sex or divorced (write the word) Date of Death 7 19 79
Age 36 Years Months Days Birthplace New York State
Cause of Death Malignant Melanoma
Certificate was signed by Betty L. Voelker M.D.
Address 308 Bay Rd. ,Glens Falls, N.Y.
Place of Burial (or Removal) Town of Queensbury_,N.Y.
(If body is to be tern orarily h ld, fill i space later)
Cemetery Dine View Cemetery Date of Burial OCt. 9 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 registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GRANT A PERMIT
to Regan & Denny,Inc. quaker Rd. ,Glens Falls, N.Y.
(Name) (Address)
the Undertaker to hold temporarily and Inter the body
(11nlerp,ker or Rerson having charge of corpse) (Inter, remove or otherwise dispose of (state how))
Dated 19 (Signed) `\(N(1.
cal 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 carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of •( -- `-(727 L 4-7.1-7vas / /Y 19
(Interment or Gissesnario )
-�-�-ram.., 1�--c--e-��-._• __ _-____.
(Name of Cemetery, C for
Section Ag4 -4,1Lot No. Grave No.
(Signed) 4-1
(Person in Charge)
Address y ti
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.