Jarvis, Nelson Form FS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ts' This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Pranary 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 N&O4 ..._.._.._
Town
Dist. No..5.$Q County WAXTaUU Village1,.31...aeaQh..8t..,G1 s..raUa.,.N.Y,
or City (If city,giveetreet address)
Name of deceased Naa.aon...+A.t...s1ar.Ai.B
Single, married, widowed, •
Sex M41e Color W . tcbr divorced (write the word) widowed Date of Death. July 2? 19..39.
Age 89 Years 0 Months 27 Days Birthplace.....c1 14bit
Cause of Death Qf.Rx'f119 Ireigi .ax" C .#Qgk&.p - 1...y.Q.aI"
Certificate was signed by Dr.....Harry....Dapan M.D.
Address 0.1.ens...Ealls.....N.....1..
Place of Burial (or Removal) TQI0..of...QCi.eenattury.,. .Ns...n
(If body is to be temporarily held,1111 in space later)
Cemetery St. AlphonsuS Qemetery Date of Burial July 2§ 19 N..
(If body Is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to Joseph F. Regan Glen$ Falls.:...N,...X.,
Undertaker (Name) (Address)
the to hold temporal-. @ the body.
(undertakecoorpersop,1 aving chargef„corpse) remove,o se dispose of[state how])
Dated y '*i 19 ! (Signed)
Local strar
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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