Haverty, John Form VS.61. 10-21-37-25,000(17-3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 QF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..12.9
Town
Dist. No..s6Q1....County ia.r•i •m Village 37.••4,411ck g2y,tve treePa}ag s Falls/raj
or City
Name of deceased John T. Haverty
Single, married, widowed,
Sex Male Color ;1hiteor divorced (write the word) Wiac?./.Ad. Date of Death April. 19..38
Age 68 Years 2 Months 21 Days Birthplace £1.ens••.F.8,1.1.s. •••M_...X..
Cause of Death CerAhral hemorrhage-4 days;nardio vascular renal ip— vis.
Certificate was signed by R. J• Sin.aleton M.D.
Address Glens Fa 1.is ; ,h?. T.
Place of Burial (or Removal) Town of aueensbu;'vvaN,v},.
(If body is to be orarily he fill in space later)
Cemetery - «1 rhori s»S Q em e t¢ry Date of Burial .4.ril..2.3.. 19..38
(If body is to be temporarily held,311 in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he 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 Seward T. Potter Glans walls. N— 7..
TTndertake r (Name) four (Address)
the to hold tempor. ., a • ,!. ..`- the body.
(Undertaker or person having charge of corpse) ,/0s n de�,ve or . ,er• = dispose of[state how])
Dated A rl i.1...22.,. 1938... (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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