Ploof, Emma Form VS.6L 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 Primary Registration District (Town,'
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER'T.FICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No...-__._-..._-_...__
Town
Dist. No 560- County Village 9
1'1 a rrs 3 South St., Glens Fal1sAN.Y.
or City (If city,give street address)
Name of deceased Mr.a Fmma P1,9Qt
Sine
Sexyemale Color white or divorced (wri eidowed the word) Date Date of Death Fah... a. 19.39.
Age 67 Years 3 Months 0 Days Birthplace.1I011traa1,...Itana a
Cause of Death Lobar PXi$3ap14 ; 1._ ,ayB
Certificate was signed by Dr. ...1I4,..L.....Havila 1d... M.D.
Address g Q . .rall.e.}. .No..Y..
Place >f Burial (or Removal) TAM..fit..QU,.B.ensbu2'y.s....DI....:Y.,
(If hod^is to be temporarily held,fill in space later)
Cemetery............4.::.s ... 1,pb.4 } e...�'e.em.,, Date of Burial F.o.b.,►....6., 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 Orville W. Collins Boame) .,...Czlens...k'a ,�s, 11....yy
the Un4erti ex to hold temporar' ..Ixl.te.r the body.
(UndertakerFeb.person having charge of corpse) (I ,remove se dispose
pose of[state howl)
Dated 4,, 19..3.9 (Signed) ... . . . ,
Local egistrar
This Permit is suf!i'ient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regu".,ions),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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