Hayden, Florence Form VS. 61. 8-16.35.5U,001) (17-14ZS)
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. 5601 Registered No. 392
Town
County Warren Village Queensbury Hotel ,Glens Falls, q . Y.
or City (If city, give street address)
Name of deceased Florence S. Hayden
sex Fe Color iteor divorcedr(married,
eithevword) Single Dec . 29, 36
g Date of Death 19
Age 7 5 Years 8 Months 19 Days Birthplace New YO rk City
Cause of Death g.ef .X`.c` . ......a.rtarosq .sros.s
Certificate was signed by Dr, Ir.Y 1.nC E. Juai er M.D.
Address Glens Falls.., N. ;.e
Place of Burial (or Removal) Town of Queansbmry, Warren UA..... .0 5
(If body is to be temporarily held fill in space later)
Cemetery Pine View Cemetery Vault Date of Burial Des.e.mb.er 31.., 19 sa.6
(If body is to be temporarily held, fill in ,,pace 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.Potter Glens Falls,N.Y.
(Name) / dr
the Undertaker to hold tempor ' �/ the body.
(Un taker or erson h ' charge of se) (I remove, or h 'e dispose of [state how])
Dated eeem'�er "# 19°� 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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