La Pointe, Amelia I!orm VS.61. 10-21-37-25,000(17-3469)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Fir 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. Registered No...-.1.A&_..___.._
5601 '.Darren Town 47 Hudson Ave. .Glens Falls.I T.Y.
Dist. No County Village
or City (If city,give street address)
Name of deceased Amelia M. LaPointe
Single, married, widowed
Sex Femal e Color White or divrced (wite the word) married Date of Death r:av 15 . 19.��$.
Age Yeas ]10 the 12 Da s Bir h lace Glens Falls : N. Y.
Cause of Death Years says---nronelhopneumonia-6 Birthplace
Certificate was signed by Dx Fa u.. enan. - M.D.
Address tens a . W. Y.
Place of Burial (or Removal) Tnwn of neensbury, N . Y.
(If body is to be teI3porartlIDlionsus held,fill in acleme to ry T.: v 8
Cemetery TT • 44 Date of Burial . ..a 19.5.a.
(If body 10 to be temporarily held,Sll 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 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 kt.S. T. 'otter clerks i all§......1?r `T.
Undertaker (Name) nt (Address)
theto hold tempor ex' the body.
(Undertaker or person having charge of corpse) ( remov wise dispose of[state how])
Dated 1`:a u..1..7..,. 19..3.8.. (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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