Colvin, Addison Form VS.61. 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
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.1..81.. _
Town
Dist. No 5601 County Warren Village 271 Glen Street,
or City (If city,give street address)
Name of deceased Achi ,.apn... A....CrQ1YiD
Male white Single, ma widowed, )widowed June
SexColor or divorced (write the word Date of Death 21, 19...�.9.
Age 80 Years 6 Months 6 Dais ' Birthplace...Q1.0 ...r..e.1.1.Z3.9....Ne...Awith
Cause of Death I em°chromu,to$ip of Irk,VOre. .y. :$.t.,;. Erinifkry QIrg...17.01il,...Q ...Liter.-liX1110113
Certificate_was signed hy. ite :tams 01...R.tb.-6..MQ.5w.. ......1),X... ,Q&QX ..a.....mitO.he11. M.D.
Address Glens Falls, NI Ye
Place of Burial (or Removal) Town of queensbi ry,,, R„_ 1
(If body is to be temporarily held fill in space later)
Cemetery Ping Vi.PM...00.1110.Tr4 'y Date of Burial June...2.3., 19..39
(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 Seward T. Potter Glgz ..EAlla,...R....Y.,
the Ufdert (Name) (Address)
Y' to hold tempora ' er the body.
(Undertaker or arpon aving charge of corpse) I move, se dispose of[state how])
Dated June 2Gg 19 9.. (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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