Lupien, Frederick Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t r 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..._.._2.14..__._._
Dist. No.56.03. County Wazzext xvagricex Glens Falls, N. 1 .
or City (If city,give street address)
Name of decea eilfredrl ek a C . ,,LAIp3, .A
Singie, married, widowed,
Se .4t 1g:...Color iil.bl.t.er divorced (write the word)....Marrisd Date of Death...Aug......28 19..40.
Age 5.7 Years 6. Months 16. Days Birthplace Q.a.na.da
Cause of Death .Angi na..PBnt,osi.s-.4..mo.. O.or.onlan:y..S.ol rastbs
Certificate was signed by B......J.. `�i.Zhg.1a tOX4 M.D.
AddressGlens..Fll� •- `.� �A��
Place of Burial . Removal)
(If body is to be -g o rid 11 apace later)
Cemetery e.. ....... Date of Burial ,.Y7 1960
(If body is to be temporarily h ,fill in space later)
The Certificate of Death containing the above stated particulars, having been presente to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accept the same f. registration, have recorded it in my Local R d with the above stated Registered
Number, on the`b,-is jf.e�`,. I HEREB1 GRANT A PERMIT
to c.....f. .. -. . G'' %Zt-044 e! .�.L a�
� i �.to; - ddress)
the .(2 •. ' to hold temporaril the body.
(Un ker or person having charge of corpse) (In ve, erwis [pow of[state how])
Dated... r3 ,dlt..,.��T,, 19l,1 (Signed)
�� .:..
Local gistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an 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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