Sheldon, Kenneth 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. F /
5657 WARREN Town, Village STAR RT. RD1 LAKE GEORGE ,
Dist. No. County or City
If city, give street address) N.Y.
Name of deceased KENNETH H. SHELDON Veteran NO
(If veteran,give name of War)
MALE Single, married,widowed, MARRIED 4-7— 80
Sex or divorced (write the word) Date of Death 19
Age 88 Years Months Days Birthplace NEW YORK
Cause of Death MULTIPLE TRAUMATIC INJURIES
Certificate was signed by S. RI C H A R D Sp I T Z E R M.D.
Address 90 SOUTH STREET, GLENS FALLS , N. Y.
Place of Burial (or Removal) TOWN OF QUEENSBURY
(If body is to be temporarily held, fill in space later)
Cemetery SEELEY CEMETERY Date of Burial 4-9— 19 80
(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 JAMES S. POTTER 136 WARREN ST. GLENS FALLS , N.Y.
UNDERTAKER me) (Address)
the to hold temporarily and TER the body
(Unlertaker or person having charge of corpse) (In r, remove otherwi pos of (state how)
Dated 4-9— 19.. .80- (Signed) ,r.._ .. .t., _ ._
Local Itegistr-
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. 6/631 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of 151-was ___..��9 19
t!
(Interment or ets.nsatIen.)
(Name of Cemetery, €fZ•
Section Lot No. ---- Grave Grave No. —,
(Signed) 1614
(Person in Charge)
Address /40----5477f
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.