Saidel, Baby boy Form vi NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIALZ(OR REMOVAL) PERMIT
S 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 CERTIt I TE OF
-DEATH, LE_GIBLY WRITTEN IN DURABLE BLACK INK. Registered Nn� .._..� '1
Town .
Dist. No..`.0.01....County *Bute A
Village 't�(3A8... i�11 ..:N.Y.
or City (If city,give street address) +1'
Na me of deceased Baby Boy Saidel
Single, married, widowed,
Sex color or divorced (write the word) Single Date of Death Apr. .1..•22- 19
Years Months Days g+ hrs. Birthplace G.Lena...F.afls••.N...ri,
t o e oTDe ----- _ _M ph xis Neonatorum
i
Harold- Peek 13 _ ... �, ..
Certificate was signed by t- - - -- -
Address
Glens Falls, N.Y.
Place of Burial (or Removal) We ...% on9 Fol a .N...i,
(If body is to be temporarily held,fill in space later) ., a,
Cemetery Tewis Gem. Date of Burial ADx:1.I.••• ••• •.....•_1tr
9 4. '`
(If body is to be temporasily held,SR in space later)
The Certificate of Death containing the above stated particulars, having been presented tome, after careful exam:
t-• G_.tl!e,same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LA 4L
I have accepted the same for registration, have recorded it in my Local Record with the above Stated Re '_
Number, and on the basis thereof I HEREBY GRANT Ai PERMIT
to $en.u..et ..R....Ray.ward - Et... dward I.T,
Name) (Address) ;
Undertekex' Inter the body
the to hold temporarily an . ,
(Uncle or a having charge o corpse) nter,re v dispo of{state how])
Dated �G .. 19. (Signed) r Local Re ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject•to ;.;
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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