Johnson, Shirley Form VS 61. 6-3-34-50,000 (17-7901)
NEW PORK 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. Registered No.
Warren Town Glens Falls, N.Y.
County Village
or City (If city,give street address)
Name of deceased Shirley Mae Jt ,p,e,pn,
Sex f• Color WI"-ttr divorced (writearried, dthe word) Single Date of Death Oct•25th 19 35
Age Years 5 Months 4 Days Birthplace Glens Falls t N.Y.
Cause of Death Broach() pneumonia
Certificate was signed by Dr......F.loy.d.....Palmer , M.D.
Address Glens Falls.. N...Y.
Place of Burial (or Removal). Glen? Falls Cemetery
(If body is to be tem�p,,, l? held,fill i ice later , ,7, -- —0
Cemetery d ,. x P Date of Burial Oct. 27t h 19 35
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the ab ted particulars, having been presented to me, after careful examina-
tion, 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 HEREBY GRANT A PERMIT
to Harold C. Stafford Glens Falls1 N.Y.
(Name) (Address)
the Undertaker to hold temporarily ainter the body.
(Undertaker or person having charge of corpse) emove,or otherwise dispose of[state how))
Dated OCt.. 2.6.t.h. 19...35. (Signed)... .... ..
Local 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.
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