Joslyn, Baby girl Form VS.6L NEW YORK. STATE DEPARTMENT OF HEALTH
OFFICIALS BURIAL (OR REMOVAL) PERMIT
to 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._.4___..__.
Town
Dist. No....E.EQ1.County warzglia Village Glens Falls Hospdtal , - Glens F
Falls
or City (If city,give street address)
Name of deceased BQ)2Y...G.121...s Q o
Single, married,widowed,
Sex P Color W or divorced (write the word) Date of Death March 2J 19 40
Age Years Months Days Birthplace
Cause of Death No complication po sz iblp hydraz }ie
Certificate was signed by Dr• nit A,, Z7,9 M.D.
Address Glen4�esatiGlens� ells New York
Place of Burial (or Removal) f
(if body is to be temporarily held,fill in spa later)
Cemetery west 3,PX1 ?..ra1, .l e0/116teWy Date of Burial march 4, 1944 19
(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 84 Warren St. Glens Falls n y
Undertakelme) Inter (Address)
the to hold temporaril a the body.
(Undertaker or person having charge of corpse) (Inter,re v dispose [state how])
Dated .Msx.ch...41 19.40. (Signed)
Loc ogle
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any p 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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