Gubitz Sr, William roan Va. Os. 0.10•2J•JV,VVV t1/-1 YLJ1
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 6Q.l Registered No. 46
Town
County Warren Village? Harrison Ave. ,Glens Falls, N.Y.
or City (If city, give street address)
tA♦-
Name of deceased 711 1.1.a.r4 E..._..lab.i.liz,,.Sr.
Single, married, widowed,
Sex Male Color White or divorced (write the word) married Date of Death Feb . lg.a.. 19 37
Age 66 Years 3 Months 12 Days Birthplace..AJ. xa.ny.s N r I.,
Cause of Death CArcinom, of Rectum ...
Certificate was signed by Dr........Jame.a A. iah.I.olds ... M.D.
Address Glens Falls, N. Y.
Place of Burial (or Removal) T.Q.471n A. ` Q.11,0.efQ.b.4:1ny, N.a Is
(If body is to be temporarily held, fill in space later)
Cemetery .'..ine view QQme.:t.ery Date of Burial F.A.b... 17., 19 727
(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 S.T•Fotter Glens Falls , N. Y.
(Name) (Address)
the Und e r...tt.ak.e.r to hold tempora ' a ter the body.
(Undertaker or person having charge of corpse) remove, or se of [state howl)
Dated Fab 1.6.,. 19..3.7... (Signed)...
L. 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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