Westcott, Amelia Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr 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 CERT27M ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. vV _....__
Dist. No
5601 County Villa Warren Townge "lens Falls Hospital, 'lens Falls
or City (If city,give street address)
Name of deceased Amelia M. destoott
F white Single, married, widowed, Wido+red April 15, 19
Sex... Color or divorced (write the word) Date of TM? th.
3 1�d d1 ebury t 'V'ermont
Age...,a...0.`� YdarsMonths......,�g... .Da B,,'r�tt�h, lace
Cause of Death erebral Apoplexy Artenea Hypertension
Certificate was signed by Eaw 'd Fitzgerald M.D.
Address Glens tails, uew work
Place of Burial (or Removal) Town of Queensbury, New York
(If body!e to be tea rarilyAl 1pd,hflll]n�u ,
19 40
Cemetery Date of Burial
(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, on ' basis_th ereof I HEREBY GRANT A PERMIT
lens New York
to ',;. ', ,. E,• . StaffordFalls ,
UndertakeiVame) Inter (address)
the to hold tempos' and he body.
(Undertaker or person having charge o corpse) ,- : j7 remove,or of se of[s to h
Dated Al? 'L ... ,0..E 19 40 (Signed) • ......... .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in whi case ransit Permit (VS No. 62) is required.
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