Smith, Rollen a�.au •u. va. u aU PI i , Vv tai•AL�.J,
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. 64
Warren Glens
Glens Falls Hospital
County Village I�
or City (If city, give street address)
Name of deceased Rol len C. Smith
t,iale White Single, married, widowed, Married March 3 37
Sex Color or divorced (write the word) Date of Death : 19
Age 67 Years ° Months 10 Days BirthplaceT..Q.V fl Q. Q.11.e.e.lis.b:i.l.S:'.,V....:1a.);'.gE } C
Cause of Death Auto Accident; C.Qmp,fra.oture2 . Femur •
Certificate was signed by Pr a.......::+.,. E. Frasier _ M.D.
Address Glens Falls N. X..
Place of Burial (or Removal) Ne Wt.....Gl..en; ....Falls., E.....Y.
(If body is to be temporarily h fill in spacelater)
i.
Cemetery • He rmonCemetery Date.of Burial Lia.re11....6., 1.937 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 All Carleton Hudson Falls, �, Y,
Undertaker
(Address)
the to hold tempura ' a ..... , .X' the body.
(Un {,taker o n having charge of curse) nt ove, or otherwise 's se of (state howl)
Datrd March per�x 19 3.7 (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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