Blackburn, Mathilda rorm V . 01. 0-to-,,,v,vvy k
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar-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 5601 Registered No
Town
County Warren Village 3.1.....fiudg.an IQ... Y.
or City (If city, give street address)
Name of deceased Mathilda BlacXbArn
Single, married, widowed,
Sex.F..arnal..e.Color 712.1.t.eDr divorced (write the word)..iLa,r-19.84 Date of Death. b , 19 36
Age 64 Years 6 Months 13 Days Birthplace Chi.c.outimi..,.E...Q.....Cana.da..
Cause of Death Garcinoma of Cerliterta
Certificate was signed by Dr... JIe. a5Shialta M.D.
Address Glens Falls,. N. Y.
Place of Burial (or Removal) 'Vest Glens Falls, N, y.„
(If body is co be temporarily held, fill in space later)
Cemetery St Aiphorisus Cemetery Date of Burial Ham.. 44 19.56.
(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 Lionel J. Boivin Glens Falls1 7 l •
(Name) (Address)
the Undertalc?r to hold temporarily a the body.
(Undertaker or person having charge of corpse) e, or ot " pose of [state how])
Dated 1,:fav arxine.r a, 19. 3.6. (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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