Lohret, Mary Form VS.8L NEW YORK STATE ARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Psi:�a Registration District (Town
Yillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE O `"
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.§..... ..._..._._
Town
Dist. No56.Qi Warren CountyVillage...(1?.is Falls HQspita).,
or City (If city,give street address)
Name of deceased Mary Q......LQhlret
Single, married, widowed,
Sex.eilaLe.Color.Whit.e...or divorced (write the word).......5. .P Date of Death zany 17 9 40
Age...5 Years 6 Months 24 Days Birthplace Glens Falls , N. Y/'
Cause of Death A0 1t0...1.1'J.tAgt1.11.41 obstructian8 days,; eonaenital band; asthmatic
Certificate was signed by....D.QJn .J7lj.c A„ &Arlo bronchitis 4 da M.D.
rem- - - Glens Falls , N. Y.
Place of Burial (or Removal) T9w4 9f Q1 ieensburyi west Glens Falls,
(If body I.to be temporar1ly held,.fill in space
p ce later) 40
Cemetery St. 1.P Date of Burial Z�uarY 1919
(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 Lim],], Jt Boivin Glens Falls, N. Y .
U e 8ker (Name) It (Address)
X4l...7�' Inter the to hold temporaril and the body.
(Undertaker or person having charge of corpse) s r other dispose o state how])
Dated...Z.a.Ylliar.X!0-B 19...Q. (Signed) - e tit
y Local Regtstrar
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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