Potter, Orville ---- •- ---
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
NW 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...??3
Town
County Warren
Village 27 Second St . ,Glens Flls, New York
or City (If thy, give street address)
Name of deceased Qryllle Eotter
37 Single, married, widowed,
sexMale Color white or divorced (write the word)Widowed Date of Death Oct. 9, 19
Age7..4 Years 5 Months 17 Days Birthplace Que ensbury., N.Y.
Cause of Death Coronary !hrombosis--10 days
Certificate was signed by Dr, James B. Shields .M.D
•
Address Glens Fallp, N,Y,
Place of Burial (or Removal)WESt Glens Fall S 2 I\T•...*•
(If body is to be temporarily held, fill in space later)
Cemetery Wa.st Glanz FAlig.. ..Q.pm.tery Date of Burial October 12, 19 37
(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 S. Z. F.P.ttQr Glens Falls NI Y.
?
(Name) (Address)
the Vndertaker to hold tempo .er the body.
(Undertaker or person having charge of corpse) re ove, or oi1sCsispose of [state howl)
Dated Q.Q.t.o..be.r 1.2.,. 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
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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