Simons, Andrew Form VS.6L 'NEW YORK STATE DEPARTMENT OF HEALTH "
OFFICIAL BURIAL (OR REMOVAL) PERMIT
g2r 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
, LE
GIBLY•
WRITTEN IN DURABLE BLACK INK. Registered No- .___
Dist. No 5601 County Warren Village 61 Elm Street
or City (If city,give street address)
Name of deceased Andrew Jackson Simons
�g� Single, married, widowed,
Sex. 1@ Color..T. it
.e..or divorc:id (write the word)....M . ,Q4l Date of Death X.une...l.l., ' 19..39.
Age. AR Years 9 Months E6 Days Birthplace Fort Edward, Wasl'k Qg..j
Cause of Death...Par# 1yS.i.9...Ag.t.414$...5...Y.rs; arterio sclerosis;time unknown
Certificate was sign4 ed _....., DTloyd Palmer M.D.
Address Glens Falls, N. Y.
Place ,f Burial (or Removal) Town of Queensbury,
(If bod;-is to be tenpiQrpri�y view
in space later)
Cemetery t'llInl6e Date of Burial 14/.a...a..'3..) 19..3.9.
(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 R. F. Lattimore Ballston Spa, N. Y.
the Undertakd °1e) to hold tempo - and Inter (Address) the body.
(Undertaker or person having charge of corpse) In move the Low])
Dated alLTI8..13`th 1939.... (Signed)...
eput y Local Registrar
This Permit is sufrcient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regu,. bons),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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