Page, Celphonsine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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. /-,-;).
Town, Village .C
Dist. No. a E<'/ County ,,`, City - 1-(-c-- a'-I',--�
�_ <<:_, or
If city, give street address)
Name of deceased .:� c.�.2 .',�_4.t- .1 .4 i-k_= Veteran_.-i.
/ (If veteran, give name of War)
) Single,married,wid ed, i
/i
Sex s.-//'/- "- or divorced (write the word) _ 4-.1-4 -1 . Date of Death � - 19..t_%
Age Years Monts Days Birthplace
Cause of Death -- -- -- ..4,(.1-�.- - u(J,?-- -;2_-z- -2 L? . .0 -7
Certificate was signed by _ .4. f,_,e .4.- _ h M.D.
Address % ter f- 4 , 7 )l-:_` _
(If body is to be temporarily held, fill-yin in space r
Place of Burial (or Removal) -1. -__ -.y f1/>:.4�` -,t-,__.__C ;n (-Ui.
P 1-} P e later)- / =
'Cemetery____ ,-1 r., ^.e-i tom; Date of Burial 19__.f
(If body ismporari ld, ilpace later)� �
The CERTIFICATE OF DEATH containing thk�bove 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 GM.NT A PERMIT
tO 4.,..4,z-n.z..,_,._. / • Li.,_L ' .e.-re 4 Vs.:---'9,t, -3/21" -,. I- 1:1-71 '--Zt.r/ --..."--- "lic.. . -t-ta---
(1Va (Address) _r
the v./:1--z,,, /� .C, to hold temporarily and . ', r the body
(Unteetaker or pe Son havi charge of corpse ,`1 (Interern6ve r)oth wise chap of (state ow))
Dated Cj?.�;4s...._. - i,7 19_ 2 (Signed)�.7 . -a.f.- _ - -x-_
al Registr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to a y part of th 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 Interment was 3 — 26 19 80
(Interment or Cremation)
St. Alphonsus Cemetery
(Name of Cemetery, Crematorium, etc.)
Section Lot No. 18 Grave No. 4
(Signed)
(Person in Charge)
Address 35 Broad St. , P.O. Box 60Q
Glens Falls, NY 12801
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.