Du Four, Clementine Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. 9
Registered No..._... _....._...._.........
5601 warren Villa e 26 exin ton Avenue
Dist. No County g �?....••.. ..�
or City (If city,give street address)
Name of deceased clementine Rigour
Single, married, widowed,
Sex fe Color white or divorced (write the word)...W.I..45..QWed Date of Death..MarE i...1e.t.s 19.42.
Age 06 Years U Months Q Days Birthplace....Canada
Cause of Death.. reIDle 1t dal multiple myeloma. 15 mos.
Certificate-was signed by Dr. D. A. Durlo •M.D.
Address Glens Falls„ N. Y.
Place of Burial (or Remmoval).. ,'own of Queensbury a Warren Q ount�T s,,, ,.
C body r to bg L 1 AApno 1flu space later) 3 d
Cemetery.... . .!... ...p Date of Burial March �' , 19...4g
(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
Nu d on the basis thereof I HEREBY GRANT A PERMIT
to Lionel Ja Bolv1n Glens Falls: N. Y.
IInd t (Name) (Address)
the 4 ' $ x' to hold tempor. dt e body.
(Undertaker or rsoa having charge of corpse) r, „ove a [s e h )
Dated March 2 , 19 44 (Signed) ,
1 epu 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
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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