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Deane, Caroline (2) 11- 4i Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tr 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._ .4.9 ._... Warren Town 27 Harrison Avenue Dist. No...56Q1..County Village or City (If city,give street address) Name of deceased lira...CarQ1iI1e....4...Shaw...DeariP Single, married, widowed, Sexg ale Color wi lte or divorced (write the word)...W.1.(1Q ed Date of Death February..11.19.41. Age...7.2. Years 6 Months $ Days Birthplace....Ne....:York..a.tate Cause of Death..GAZAbr.a ....heMOIThage..i...Clay.;....arty'. .0...S.Cle.r.OSia...l....i.ear Certificate was signed by Dr*... gAg.... ....5114ild1S M.D. Address xlp,??. ...F#la, .s...NAY,..... Place of Burial (or Removal) Tpwn...of....Queenaklury.f. (If body is to be temporarily held,fill in space late* H Cemetery 2,14ae..V .eW VA)a I-t Date of Burial VebruAry..15 1941. (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 Harold C, Stafford Glen,5,,,F ,15 - (Name) (Addre it the tkiGlerta.�.er to hold temporarily a d .r'ri t e body. (Undertaker or person having charge of corpse) ( t r mo e,or of r s die s of s ho Dated ''.frbxuary...13.t 1. 19..41. (Signed) s j, pu y Local Registrar This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local } S'H -. .CACn Oyrow00 ft Lai° ,•1 " yw " enc 0 r+ ..• { i N fii° w �P. aA ova ; -• -°rw.""'� w �s»° wwRofDaa° �, E.y'oo ^a i y�Ht+i p79? d �, " o a eo »...." ..eo r.c •e ro " : W LrJ '"' G..'3'< o CC e"oo p�w w�-.i 0 e.a cue a•a, •e...) " C .ty"p.E. 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