Stoddard, Stewart rorm V . cu. 0-10-3)-,U,UUU (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..56.01 Registered No 302.
Town
County ar.r91:1 Village.].7 Harl.em. .S.t.....t.G.1.ens.
or City (If city, give street address)
Name of deceased
Single, married, widowed,
SexFeinale Color White or divorced (write the word) Wid.0117..0..d Date of Death Qato.laer 19....aa
Age 79 Years 0 Months 16 Days Birthplace...7.1.e.stchester Yor:
Cause of Death Oar.g.incnia....
Certificate was signed by Dr. James B• Shields M.D.
Address Glens Falls, New York
Place of Burial (or Removal) Town of Q,Lieensbury..& Tiarr.en York
(If body is to be temporarily held, fill in space later)
Cemetery Pine VieW cOIlletery Date-of Burial October 61 19 .3.6
(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 Harold C. Stafford Glom . .. Y.
(Name) Ad•
the Undertaker - /.00"' the body.
to hold temporaril, d Int-r
(Undertaker or person having charge of corpse) (Inte mo j02(1111caltilt,"chspose o e how])
Dated October 6, i9. Q (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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