Prince, Emede Form VS.6L 10-21-37-26,000(17-3469)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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. 176
5601 ? arren Town Glens Falls Hosni_tal
Dist. No County Village
Or City (If city,give street address)
Name of deceased tied e Prince
Single, married, widowed,
Sex?.Tale Color white or divorced (write the word) O4.13.F.I.0 Date of Death J.U3aa...11., 19...ass
Age n Years 11 Months 4. Days Birthplace a1.en.s...Es.11s., .11I.....`T......
Cause of Death General Feritonitis-14 days
Certificate was signed by Dr. L. J. Butler M.D.
Address Glens Falls,, N. Y.
Place of Burial (or Removal) Town of Q1ueensbury, N. Y.
(If body is to be tempos ily hey'.fin in space late
Cemetery at. n1Dhonsus "ern etery Date of Burial June 14 , 19 38
(If body is to be temporarily held,till 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 a3uard....T......Psa...ter Gle.ns....Fa1.ls..,...nT......Y.. ,...
Undertake/Pie)e r t ake r me) (Address)
the to hold temp the body.
(Undertaker or person having charge of corpse) r ve,or ot�e ose of[state how])
Dated .Tl l ae...li.,. 19....3.8 (Signed)
... .. . . . .. ..
Local Re str
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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