This is an official New York State Department of Health Report of Death stub, dated February 1933, documenting the passing of Stewart D. Fuller, a 78-year-old farmer from the Adirondack region of Upstate New York. The form, printed on age-toned paper with visible foxing and a deckled left edge suggesting removal from a bound ledger, records Fuller’s death on February 4, 1933, in Bolton, Warren County, from chronic bronchitis, certified by Dr. J. L. Huntington. Handwritten entries in dark, legible cursive reveal Fuller was born on January 28, 1855, in Johnsburg, Warren County, to John W. Fuller and Katherine McDougal, with his mother’s birthplace listed as Argyle, Washington County. He was married to Helen Hewett, his occupation recorded as “Farmer,” and his last date of work noted as January 1933, reflecting the persistence of agricultural labor into old age during the Great Depression. The form includes standard demographic fields of the era, such as “Color” marked “W” for White, and a space for the informant left blank, with burial listed at Warrensburg. Accompanying this death stub is a handwritten list of survivors, composed in pencil on lined, yellowed paper with a torn right edge and a small piece of green adhesive residue at the top left corner. The list, likely drafted for an obituary or funeral service, records “wife” and three sons: “Burt J.” of Utica, and “Herman” and “Ottest” (possibly Otis) of Bolton. A single brother, “Fred.,” is noted with the location “M. Creek” (likely Mill Creek). A bracketed section enumerates grandchildren—“Harold,” “Marjorie,” “Edward,” “Francis,” and “Virginia”—followed by “Several nieces, nephews + Hosts of Friends,” a phrasing characteristic of mid-twentieth-century American funeral customs. Together, these documents form a cohesive genealogical record of a rural New York family, tracing Fuller’s lineage through his parents, his marriage to Helen Hewett, and his children and grandchildren, while the death stub provides official certification of his passing during the depths of the Depression. The survival of both the government form and the handwritten survivor list offers a rare dual perspective on a single death event, capturing both the bureaucratic standardization of early twentieth-century vital records and the personal, handwritten memorialization of community and kinship in the Adirondack foothills.