Duchaine, Eustashe Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the PrAm.,--7 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. ' FLegistered No....g...9.9._____
Town
Dist. No 5601 County Warren village42 Hudson Ave. Glens FallsiN.Y.
or City (If city,give street address)
Name of deceased-Eltlata.4k10....D.INAAiKIP
sex Male hit Single, married, widowed,
Color -e or divorced (wrieA the word) wi do we cl Date of Death Nov, 9, 19 39
Age 80 Years 3 Months ''.* Days Birthplace Camda
Cause of DeathQar.d.i.a...v.a.acular...d.is ea s.e:-.1..y.r.....
C-ertificate was signed by - - - -1:tr.,, -Harry- .De.p.an. M.D.
Address Glens rafils s. N. yt
Place of Burial (or Removal)
(If body is to be temporarily held,fill in space later)
Cemetery $t A. .Alpho.n.au.s. .Came.t.ery Date of Burial Nov. 133 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
02.QX1A.EA.11.e. ..DIA...Y.,
Undertaker(Name) inter (Address)
the to hold tempora * the body.
(Undertaiker or[Amin having chargszio4 corpse) , ov ,or the of[state how])
Dated Lvov. ..t.‘...,, 19 (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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