Collins, Harriet NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT �j.� J�
agi-This Permit can be signed only by the Local Registrar(Deputy or Subregiatrar)of the Primary Ragisistra..
Herr District(Town,Village or City)in which the death occurred after the FILING and acceptant of a COR.
RECT AND COMPLETE CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLLAA
Dist No.. Q1 R 's No.--
County.—
War __ Date of Deat1 C .L.2 1--a...I .t�
To of IJlens Falls, 14. i. Sea.-._. Age 6 Yrs. Color-_- -_-.......
lage,or City' — - (Or Mos.)
(If city,give street address)
Cause of Death--_--_-_ ----.__._--_--___-_-_---_____.—.-
of Burial or Remov- . . J
Place ewet.-
`C�netery i/o/./s ` - --_ -------_--------Date of B / i"qe t.`
/ �.4
Certificate of Death of (Give full name of deceased)
having been presented to me containing the above stated particulars and, after careful examination
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 Registered N ,and on the basis t} o IL.2....„REBY G NA PERMIT
above
de _ (. ..
--__--- AO. 2 4 the ..•y.
U r or person having charge of corpse)
Dated. 1 - - =9 / (Signed)._
- Ill //
Local Regis
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 regulation.), uniess remove[is by common carrier,in which ease a
Transit Permit(VS No.62)is required.