Mason, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qs�' 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. //
Town, Village Registered No. `7—
Dist. No.-�Zar County Warren or City City of Glens Falls
(If city, give street address)
Name of deceased Carolyn A. Mason Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex Female or divorced (write the word) ..Widowed Date of Death .Feb. 4 19 8.0
Age 69 Years Months Days Birthplace New York State
Cause of Death Cerebral Vascular Thrombosis
Certificate was signed by Richard T. Hogan M.D.
Address 325 Main St.,Hudson Falls, N.Y.
Place of Burial (or Removal) Town of Queensbury, N.Y.
(If body is to be temporarily he d fill in space later)
Cemetery .P.ine View Cemetery Date of Burial ..Fe.b.. 6 19 80
(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
PERMIT
to Regan & Denny,Inc. Quaker Rd. , Glens Falls, N.Y.
(Name) (Address)
the Vndorta,ker. to hold temporarily and Inter the body
Dated ndertaker.': erybn hc)ng charge ofMgr-se) r emS, orcerwt dispose of (state how))
rfa— �f (Signed) t�2 'r
Local egtstrar
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) (9A2-205)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 4?Il� was ='''fi 19
(Interment or Ciernrtonf`
(Name of Cemetery, CktaraA
L.4114e'4.,14 _z '7 i Grave No.
Section Y Lot No.
(Signed) 4
(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 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.