Newcomb, Henrietta corm Vb. 01. 8-16.35-50,000 (17-1423)
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. /f
Dist. No. J �.Q/ Registered No.( 1P
Town
County Village 16 Broad Street'
or City (If city, give street address)
Name of deceased I en 'ietta NQWQ.01)1
F lhite Single, married, widowed,
did(rwed 2
SexColor' or divorced (write the word) Date of Death May 19 36 Sys
Age 78 Years 10 Months 22 Days Birthplace Gle .s Falb s , N Y x�iai s
Cause of Death .r-t.e.ri.o s-c-1eros-i.s. .5 ys--, diabl.ti.s ms1-1i•t.i•s•....5. yra.;---_.yn-te•stJ,na1•-neph-
Certificate was signed by Dr George A, Chapman M.D.
Address Glens Falls , N.Y.
Place of Burial (or Removal) West Glens Falls (Glens .Falls RD 2)
(If body is to be temporarily held, fill in space later):
Cemetery We St Glen* FaliS Date of Burial May 14th. 19.. .a..
(If body is to be temporarily held, fiil 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 Ne .s o , L...... .al ..i.. .., Zor..t Axir ..,.... C....Y.
(Name) (Address)
the Undertaker to hold tempora ' and Inter the body.
(Under„tilker or.pejsQt`_having charge of cq ,e) er, re ve, ors" ise state how
Dated y 14 WI , 19 c7b (Signed) ,
eputy 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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