West, Grace NEW YORK STATE DEPARTMENT OF HEALTH V
OFFICIAL BURIAL (OR REMOVAL) PERMIT
NW 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.
Dist. No....5601 Registered No, 4
Warren Town Scripture NursingHome, Park Street
County Village p
or City (If city. give street address)
Name of deceased Gra.es.....L.. W.e.st _..
��t� Single, married, widowed,
Sex..F Color..Wb1it_e..or divorced (write the word).......8iI: ;1,g Date of Death Jany 2 19 38
Age 73 Years 11 11uunths 5 Days Birthplace...G.leaS....F..all.s, NY................................
Cause of Death.Fr.9.111.....grippe infection 1 mo; arterio sclerosi s 5 time unknown
Certificate was signed by Dr. Floyd Palmer _...._..,__.M.D
Address Glens Falls NY w_.._............._...
Place of Burial (or Removal) Town of Queens bury
(If body is to be temporarily held, fill in spat I ter)
Cemetery Pine View Date of Burial Jany 4 _ 19 38
(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 Wilma rth & Son, Inc Glens Falls NY
Undertaker(Name) (Address)ter (ndaress)
the to hold temporaril `
nd � the body.
(Undertaker or person having charge of c r se) move, or ise dis tate h I)
Dated January 4th 19 bi (Signed)
eputy 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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