Clum, Marie 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. •
5601 Warren Town, Village Glens Falls
Dist. No. County or City
If city.,,give street address)
Name of deceased Marie Reith Clum Veteran PO
(If veteran, give name of War)
Female Single, married,widowed, Married 10/11/79
Sex or divorced (write the word) Date of Death 19
Age �'q Years Months Days Birthplace Canada
Cause of Death Respiratory' Arrest
Certificate was signed by V' Koh M.D.
Address 52 Park St. , Glens Pails, NY
Place of Burial (or Removal) Town of Queensbury, NY
(If body is to be temporarily held, fill in space later)
'Cemetery Pineview Cemetery Date of Burial 11/3/79 19
(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 Carleton Funeral Home, Inc. , Main St. , Hudson Falls, NY
(Name) (Address)
the C. Bruce Wetmore to hold temporarily and Inter the body
(Unlertake pr person having charge of corpse (Int rem 4or wise dispose of (state how))
Dated 1 � 197/ (Signed)
Local gistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any art 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) )8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
_
Date of v, / ��
as / � 19
(Interment or Cre2fiation)___
` �� e
(Name of Cemetery.
�/ �'--M-•^-'^^^ -*^
Section Lot No. "--5 n�'---1irave No.
(Signed) /l; .e��z7a,-.:
(Person in Charge)
Address %/ � � '� "' !� —� ?.
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.