Cohen, Samuel Form VS. 61. 8.16.3 5-50,000 (17.1423)
NEW YORK 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. 5.601 Registered No 21.4
Town
County Warren Village Q.1,ens Falls H..sp. .#e.
or City (If city, give street address)
Name of deceased Samuel Cohen
Single, married, widowed,
Married June 24 1936
Sex'viale Color 3h� to or divorced (write the word) Date of Death ,
Age 4.6 Years 3 Months la Days Birthplace R.s.sia 4•a•b.s c e S s
Cause of Death Septicaemia following. perforated carcinoma. of e,eoQn , .n:3.._c.Q.1.Q ilith/
Certificate was signed by JQhrl H+..,. ai:I.a .•Q•l _ M.D.
Address Glens Falls, IT, y,r
Place of Burial (or Removal=}Me$to Glens E.. . -.1.q., N,. Y.
(If body is to be temporarily held, fill in space later) 2 G
Cemetery Jewish Cemetery Date of Burial J.L1X a Z.4., 19 36
(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+y basis thereof �Ipp HEREBY..}} GRANT A PERMIT
to LQ.t...e.X 'a.. .i.X.g1.�%..k.Q1.. Cti..l.el.S Fall,., a. Y..
(Name) (Address)
the jnS .!a.I'..ta.:*..X' to hold tempora • ter the body.
(Undertaker or person having charge of corpse)
ve, or .tf dispose of [state how])
Dated June 24:,,, 19 5£ (Signed) .... ...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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