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Goodrich, Leo Form vs.(IL NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT yr This Permit can be signed only by the Local (Deputy or subregistrar) of the Primary Registration District (Town, Village, or City) in which the death occurred after the G and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No......1.7.Q... _ . _ Town Glens Falls Hospital , Glens Falls Dist. No 5601 County Warren Village or City (If city,give street address) Name of deceased Leo Goodrich Male White Single, married, widowed, Chi 1 d D Jul 21, 1 40 Sex Color or divorced (write the word) Date of G th 19 Age Years MonthsDais 1 hour Birthplace lens tails, N Y Cause of Death Prematurity( 5 months 6station) Certificate was signed by bwightV."'sawyer M.D. Address Gl,ells m 11 s , NY Place of Burial (or Removal) West' r'lens malls� N''' (If body is to be to rarily.,h5ld,fill in space later) Cemetery bt s phonsUs Date of Burial J$ly 22, 19 40 (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 Numbers and on is thereof I HE GRANT A PERMIT to t�arold .btaftord Glens Falls* the Undertaker(Name) to hold temporaril -' In I') the body. (Undertaker or person having charge of corpse) -- (Inter e ,' se Po of[state how]) Dated loll =....221 19...4Q (Signed) ..,. . ..... .. . Local tray This Permit is sufficient for the Removal (end 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. C•'H'o s•go° w �•w •m � � n o $ w00 $ n L•,° -, xro � ywti � na a p....iEn ,"� g x 4 � � crdp D = , .-- "'::$ w"'Y w �» ° =ioC'aw�afDaa•° � Hoo °p �4 B7 d 'Uv? III C�9 • aB 8....i. ta ° w y 3 w sx8 ti n n E o ,, a ro ti ,, o S e r" Fy .y.• U. ta w'y 0-eo et, '0•aq c°3 ♦W ti ct n .--,_,.. -"12 �' y n P M cn cm '�i l'l dr 05 �i xo , ° 8� ° a0 a.aC � w o•.. .....r+.-• yN ° o y w a.,-• ro as ...o n n toy ro a p rey h.� 2.fir 0 VJ m x< P•` 6 n °.. y .. CO A:0-° ro b O a a,y n n w, Co [moo=- C ,OQ = `,•M a ti a,.O•O-ti G. 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