Merritt, Annis Form VS.8L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rr 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.._ _ _ ....
726 ashin ton Town
Dist. Nos CountyW g Village1. 2..A.ohXl...`>J t.r e e t
• or City (If city,give street address)
Name of deceased&unis... xxiti
Single, married, widowed,SexEemale..ColcWhit Widow
e or divorced (write the word) Date of Death Nov13 1942
Age..a2. Years Q Months 9 Days Birthp1TcQNXl. Day Cox N,Y t
Cause of Death Myocarditis
Certificate was_signed by Ge Qr ge...M..Q.as eY _ M.D.
Address ausiag fl Fa.US N.Y.
Place of Burial (or Removal).TQYKX1...Q1le'.PAsbury Warren Co. N.Y.
(If body is to be temporarily held,fill in space later)
Cemetery k'iz7.s. V.. ew Date of Burial NOV. 15 1942
(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 PERMIT
to...R.oge.r.s...:&..Cax (.@�a.e.ton...ii.G.a.. l Carleton) Hudson Falls N.Y.
(Name)
the Ltnd.e.r.takar to hold temporaril and Xlt".�addres8)
the body.
(4U_ndertaker or person having charge of corpse) (Inter,rem or erwise diso•- of[state how])
Dated... IAX.....7.5 194.2.... (Signed).. . ...flt.!. ,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio of a b••y to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in whi case a Transit Permit (VS No. 62) is required.
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