Housman, Samuel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fl 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. 5601 q
Registered No....3,.it ......_..__..._...
Warren TOW° 16 First St. Glens Falls: N. Y.
County
—_......._....................._._...._._........._._...._._....._.................................._....... _ L'illage_- a
or City (If atty. dire teryee address) D
•
Name of deceased_-_..._$&murk_ Ho-ysm1n_
male Whiteoingle, married, widowed, Widowed May. 18 37
nSegpcs8 Color._..__._._._.___or divorced (write the word)__._....._...._........_.__._._.___.Date of Death
.._._. .__....._3'._._.�/�j19._._...
e.__.-...._____Years_....__'>f.._._.._._.....Months-__._.__.._.Days Birthplace Karakoef t._�!'4O LLta,
Cause of Death.. Myocardial failure-1 da. ;arteriosclerosis _•._.•_._.__...__ _
Certificate was signed by__..1)T._a.._$.aUl._.YaLi _____._. .__.._..� M.D.
AddressMena rAlj$...,_.ILL.._.Y..._,..........._....._._._....._._.__._._....__.__.__._._._._.._._.
Place of Burial (or Removal) West.._Diana._.F.al.ls.r....N...._..Y.._._._._.__._._....___._._.__._.___.__.�.____._.__
Ili body is to be tempor fill in space later)
Cemetery 'Jewish i s1 Cemeter _ _.Date of Burial—_..__May 19, _..__ 193f_
(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 sated Registered Number,
and on the basis thereof I HEREBY GRANT A PERMIT
to
Loren W. Singleton Glens.._Falls,. N, X.a_.____....._........_..__._..
Undertaker (Name) ("d""")
the.__.____..._.___._...._.____ _...._._._....__.__.__ ......._._._.to hold tempor a .. er._ _the body.
(U try aw listing change of sore) / ( rat more, or of [state boat)
d_Datena "aat J_...._.e.._._...._._..19-4_.S_. (Signed _.y( _ ...______.... _._ . ._.._.............__. __._.__
Lots( note
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.
-..c ._ „e n a •x"' •o. n 38 •
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