Roberts, Lucy Form VS.6L 10-21-37-25,000(17-3459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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. 3.._...__
barren Town 39 Broad St. ,^lens Falls N
Dist. Na.��a.Q.� County Village a v• s..t
or City (If city,give street address)
Name of deceased Lucy Poberts
Single, married, widowed,
selemale Color white or divorced (write the word) widowed Date of Death Jame 1.5 . 19.. .
Age 88 Years 7 Months 10 Days Birthplace3t.Edward .P-a,,, nnada,,,,,,
Cause of Death pulmonary Edema-7 days
Certificate was signed by Dr. h arr.•y Denan M.D.
Address Glens Falls l : . Y.
Place of Burial (or Removal) west Glens Falls, N.Y.
(If body is to be ors held,fill in space_later)
Cemetery • `A 1 fonslls Cemetery Date of Burial -ramp 17 , 19.3 .
(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 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 Lionel Boivitl. ale 1.§...FoliSA...N.,",
the Un d p r t a'_ (Name) to hold temporal-. y ,,.illt.OX (Address) the body.
(Undertaker or person having charge of corpse) ,remove,or o rwise dispose of[state how])
Dated ,Tune Lb.., 193R (Signed).. .
Loca 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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