Smith, Orville w
Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH I
OFFICIAL BURIAL (OR REMOVAL) PERMIT
£' 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_ _3......_..__._._
Town
Dist. No..P. .R.1,....County...:C r.r.c.i? Village Glens Falls N.Y.
or City (If city,give street address)
Name of deceased Orville C. Smith
Single, married, widowed,
Seiglaie Color...:&' or divorced (write the word) 77i do wed Date of Death Jan. loth 1940
Age Years d Months 25 Days Birthplace Horieon N.Y.
u 1 enm rha- e rterio-Sclerosis old r7e titn _ 'r,
Cause of Death.......0 Y. '. ...: 4 ...�. .......
�' lflcate was r tied-by`-___ Pr..t.:13 9yd, Palmer M,D, _ M.D.
Address Glens Falls, N.Y.
Place of Burial (or Removal) Tsa n...of. ..Q.U.eAra13X:y...Li..Y...
(If body is to be temporarily held,fill in space later)
Cemetery h:tI10 V7,g.d. .0.111.0.-.Le :y Date of Burial Jan.l 3 t,h 100
(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 Glens Falls N.Y.
(Name) (Address)
the u.nde.l.takar to hold temporarily and .Inner the body.
(IInd ker or personpaving charge of corpse) (Inter,mpg"o e dis of(state how])
Dated... 4 ...l..i..C4 19 6.14.. (Signed)... ....lam: i h �
Local Reg!
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),anima removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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