Washburn, Flossie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
nr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No 5-
i_ —,--1 Town, Village
Dist. No. ,,Sko b ( County Warren or City Town of queensbury„ N.Y.
(If city, give street address)
Name of deceased FiOSSiQ M, Wash:burn Veteran NQ
(If veteran, give name of War)
Single, married, widowed,
Sex Female or divorced(write the word) WidowedDate of DeatIan. 1 5 19 80
Age 83 Years IVIonths Days Birthplace New York State
Cause of Death Nitrogen death from poor nutrition
Certificate was signed by S. Richard Spitzer M.D.
Address 90 South St. ,Glens Falls, N.Y.
Place of Burial (or Removal) Town of Queensbury, N.Y.
(If body is to tie temor oilv held,int:iu a soc& later)
Wes ulens rails uemetery Date of Burial Jan• 18 19 80
Cemetery
(If body is to he 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-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PE: IIMITRek;an & Denny,Inc. Quaker Rd. ,Glens Falls, N.Y.
Uker(Name)
nderta Address)
the to hold temporarily and I er the body
(Undertaker or person having charge of corpse) (I ter, re ove, or er Ise dis e of (state how))
Dated 2.Ag",,— /if — 19 (Signed)
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) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of- Ci)3 a '� was _ L5? 19 g'
(Interment or
,
(Name of Cemetery, ,
Section Lot No. Grave No.
(Signed) " ' '11-P
(Person in Charge)
Address '` A
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.