Rosen, Harry Form VS 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL)igg'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. / S Y Registered No.
70roY.41
County ESS.EX- Village T.I.CJNDERQ•Gi
n cit.7 (If city,give street address)
Name of deceased HARRY ROTE EQ.5IN I{
Single,married,widowed,
Sex..M.a1.e Colcth.ite or divorced (write the word) Ma-rried Date of Death MaX' 29 193.5
Age . .0 Years 4 Months.6 Days Birthplace 11.' • RiAta..a.n.d.,. 1.I...
Cause of Death St X'U: OCS?•e•C• ,•Q Meni -ibis ,-..
'Certificate was signed by P•P•d •Cummins
M.D.
Address Ticonderoga* N.Y.
Place of Burial (or Removal) Glens Pails .N..Y.
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial liCar'.ch 3.1 1935
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated 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 John F Gurarnirlg T.ica.nd.era.ga N.......,. ,
tt it (Name) (Address)
the to hold temporari:�,alld • I.ntr..r the body.
( taker or pe son haying charge of corpse) /%j�,��„,.( er,remo, or 6th a dis [s o ow •
Dated //� 19 3 (Signed).—ev.. -c c- - C-
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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