Glassbrook, John Form VS.61. NEW FORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. 8
5658 Town
Dist. No County ,'Ja 'rpn Village S.ti.i? lSr Or g.c
or City (If city, give street address)
Name of deceased Jo1in u .a.a.$brq®k
Single, married, widowed,
Sex....11 Color v1 or divorced (write the word) Widowed Date of Death N.QV....28 1940...
Age 92 Years Months 17 Days Birthplace....4„tony...h .reek
C use of Death Corornury Thrombois
Certificate was signed by C ?E.Rog e r s M.D.
Address adl ey
Place of Burial (or Removal) G.1.ens...I+.a11$
(If body is to be temporarily held, fill in space later)
Cemetery P.ine...`.f t.PVii Date of Burial Dec....1 19.4.G..
(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 Irvine Drnsmore Corinth N.Y.
(Name) (Address)
the ndex t .ker to hold temporarily and t.e.r the body.
(Undertaker or person having charge of corpse) 1/I "ter,rem or otherwise dispose of [state how])
Dated �`O.V....t.9 19' 6 .(Signed) �..`a-t
Loc_ egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to an 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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