Davignon, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy oil 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 Ot=
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No... 5601 Registered No. 334
Town
County War.ran Village29 0.1 Fa,lls, N, ',t
or City (If city, give street address)
Name of deceased aaN.:.€ I1Q.?
Single, married, widowed,
Sex mete Color white or divorced (write the word) married Date of Death December 111937
Age 5.9 Years 6 Months 2 e Days Birthplace Glens Falls, N, ,
Cause of Death Coronor,y occlusion—
Certificate was signed by Virgil D. Selleck, Health Officer M.D
Address Glens Fa.,l s, N. Y,
Place of Burial (or Removal)
(If body is to be temporaril held, fill in space later)
" }'ermance CemeteryDate of Burial December 13 37
Cemetery x�it • :....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
t> Harold C. Stafford Glens Falls, N. Y.
(Name) (Address)
t` e Undertaker to hold tempor Inter" the body.
(Undertaker or prson having charge of corpse) cm v t dispose of [state how])
Dec . lo,. 19 37 (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
ear other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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