Jenkins, Baby girl Form VS. 61.. 8-16.5).)U,VUU (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dir 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. 6 a! Registered No.
Town
County '°f ar r e n Village Glaris Eal ..s
or City (If city, give street address)
Name of deceased Stillborn Baby Girl Jenkins
Single, married, widowed, ,
Sex fertal€Colorwhite or divorced (write the word) Date of Death Dec. 16th 1936
Age 5.t.j1..i..b.Veziis Months Days ri
Birthplace Ga ..uM F all e..s. :v.a. '.R
Cause of Death multiple loos of cord about neck causing relative
s•tro7 "t.'"ES•'fltri' 01 curd.
d.
Certificate was signed by 141'.., - •q•a;1-1 " Tx-: it 1411 •et-t M.D.
Address aleaa 1+a .I.w..s.'` ...L:..
Place of Burial (or Removal) Pine view 0e-22t2e•r;
(If body is to be temporarily held, fill in space later)
December 17th 36
Cemetery ..�i.:tl.fv 'lieu C.e. 'I".fu.e.l.l� Date of Burial x 19
(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
arold C. Stafford Glens Falls 2 IT.Y.
(Name) (Address)
the U.n.de.r.t.a.k.e.r to hold temporari d in tar the body.
(Undertaker or person having charge of corpse) (I e , or otherwje��7Sisp e how])
Dated .D2..e.e bet 17 .k� 19 j� (Signed)
((�� L/�./r. _.....
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o a to any art of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Trans t Permit VS No. 62) is required.
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