Potvin, Wilfred Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 CERTICISATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. J6
Town
Dist. No..5C Q1....County...WZ'.en Village Glens Fa ,l.s T♦Y•
or City (If city,give street address)
Name of deceased Wilfred Potvin
Single, married, widowed,
Sex M Color W or divorced (write the word) Married Date of Death far. 16th 19 4Q
Age 51 Years 2 Months 26 Days Birthplace Bourvt,t Ontario
Cause of Death 40przyxtstatzt Lagrippe,Pulmonary Abcess 5 Days
Certificate was signed by Harrx Depan M.D.
Address Glens Falls N.Y.
Place of Burial (or Removal) West Glens Falls N.Y.
(If body is to be temporarily held,fill in space later)
Cemetery ate... lP.1710MB QUl a Date of Burial Mart 19th 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
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to Lionel J. Boivin Glens Falls N.Y.
Undertaker (Name) Inter (Address)
the to hold temporarily an . the body.
(underi$k®r:r nepgouh aving charge of pprpse) r,remov r s i .use of ets #aw])
Dated BBtal�all'' 19 'tlJ (Signed) .,1..
Local Regis.ar
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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