Clemens, Elizabeth Form VS. 61. -
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr 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 CERTI•FICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. 5657 Registered No.
Town
County '�'arre U e ueeusbury
(If city, give street address)
Name of deceased .i.*Ripe th........LA Clemens..
• Single, married, widowed,
Sex...i1011a11Color Y$i.t.e.or divorced (write the word)3larried. Date of Death...,Apr.4.1....24.th.,...19 3.8
Age 37 Years 5 Months 21 Days Birthplace Weat...Ghazy N..Y..
Cause of Death AQ.M...0 DilitatiOn •f Heart
Certificate was signed by .K.11.3ar.th.o1D.IIen M.D
Address 19.1 Glen....S.t., Gl.ens....Fal.3.ia
Place of Burial (or Removal) See.Zy..e Cemetery
(If body is to be temporarily held, fill in space later)
Cemetery N Date of Burial April 26.tk., 19... .341
(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 Joaeph.... ..,. Regan 221 Glen St, Glens calls, N.Y.
(Name) (Address)
the Untertak.es to hold temporarily and inter the body.
(Undertaker or person having charge of corpse) ter, remove, or otherwise dispose of (state how))
Dated Apr.i.1.. 26.th., 19..38 (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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