Fassett, Mary Form VS.St NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fr 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../.G
Town
Dist. No J-alf County 4'ax:1-:012 Village L .... Q .tftP.3.111...5........i?a..Qx).S....'Ii.a,.a..S.,...N....Y.
or City (If city,give street address)
Name of deceased Rally 7 ....Er>.z e.tt
Single, married, widowed,
Sex F Color W or divorced (write the word) L ar.r.ied Date of Death May 16. 194°
Age...69 Years --- Months 25 Days Birthplace %J.ax1.s...Ea.Z.1.S.y. .DL.Y..
Cause of Death C.e.r.e ral...Iiemaxahage.... Car.cli.a.c..0 s.cal.ar:...di.s .ase.
Certificate was signed by.......Har'ry....DeT..an. .,.<s M.D.
Address ry Xl�1.Qa.... a.1.1.a...NA... T.a....
Place of Burial (or Removal) '-'tie*lr Glens Falls N. Ye
(If body is to be temporarily held,fill in space later)
Cemetery t......A143hanaus Date of Burial I ay....1.a 190..
(It body is to be temporarily held,fill In apace 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 Lo.r.en. a 'J7,n le.toxl. 6.8. .i 1 gfr...St. ,7
.... "ls.ns.....:a 1.1.s. ii....;Ts
(Name) (Address)
the. UXI.d.Q.x t ox' to hold temporari y d LUte.r the body.
(Undertaker or person having charge of corpse) (In r ,c ,therwiae dispose of[state how])
Dated .V:a7...16., 19.4"' (Signed) .. . .
• Loca egistrar
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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