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NAME OF ~ ~EN6TN OF . Retisteced Na........2RZ....F..+........»...
HOS?ITAI O~ STA IN TO
u~sinut~a~ S.LfiIYs~tFA~LS HOSPITAL ~ oR nuw~ t WK
(u ..e ta ao.pital.r i~taiM. sir. strat .aara..r Me.ti.y .
~ vt11i1 lYddetlCE ~
of daessed: Stata.......»..~IP.~t...~QT~.......... Cosmq~~~......... Tona..Q.u~;~~Lx....--- ~
L widewa vit~i~ it~ aapaW li~ibt Y~t NO ~ STREET
r. ,h;a~.o... r.~,.t ~rss p xo pc /10D`~ Kat t ski 11 B ay
1. NAM$ OF ~e - 4 o~?tti (~W (m7) 9)
D~cs,ns$D ~~1ALTER D PALMER SR o~?n+ June 1
soc a co~oa o~ e~ si~~. w?wEO vnoowr~. iF w?eiuw. w~oow~ oa orro~. w...e
Male J White i«~• Eva Paimer
t. DATE OF ~I~TH N. AGE~ ~(Y~~~aet IF UNDER I 1fFAR IF UNDEt 21 Hti. 11. tltTFi~LACE (iuu oe l~si~ artrl] ~ iL CITIlFN OF VYFiA?
Wt ~f) tl~ ~ COYNlatrrUSA
6/29/1894 I 72 I ~L ~ ~ Giens~ Fails,, N_ Y_
is.. uwµ oocu~~T~oH cc.~.. ~.t .c a... .t ~..r~ r~. ~ ur. ~u~ oF ws~rc~s o~ uiovn~r , .
Contractor Buildin¢ ,
i~ ti?n~~s ~ u. won~Y wUU~r~ w?~
Frank Palmer Mary Centerbar
ti. WAS DECEASlO EYER ~N U. s. ~uwr~c FoRCESt n. socu?~ sccuiun No. u. i~o~u~Y tu?wt nocRrss
i""'"`""k""'~ cu'"'`~*"""`+~"'~"`~°`~ s, Walter Paimer Sr Kattskili Ba N. Y
It. CAYSE OF DEATH (E~tes oab ~ s+w~ o~ ~ iN) INTERYAL tETWEEN
?/1lT 6 DFATH WAS CJ?uSrA tY: ONSfiT AND DEATM
. ~ tu~nu?~ cr?usE tirem; a
~ .°o~-~a . m' Pyelonephritis
.ea. ~a I ouE To nI
nw w~s - _
' ti~ w~~sd~uL ~
O oiw Int. ~UE TO (c~
tAtT 11. OTHER S16NINCJINT CONDIiIOiti CONTtItUTING TO OfrATM WT NOI RELATiO t~i . AIITOK
IN ~ to n+~ reuuw?~ conomoN ui ru~r ~ y mxo
~ ~ Arteriosclerotic cardio vas disease Diabetes mell' s ~c~°~'
r~?a°c.i~oE• ~°s
a~i ogc~u~ How uuu~nr occuu~. t~,w•••c W.r ~..e t.~ r..e ro.t=1k. ~~va m Z-
U S~d~r c° ° c~ o
21a TINJ~"~i1~Y F Hwe ~J D.~r Y.ar . A~ ~ Z A O
~ y. a. T? - - -i
~ 21d. INJilIY OOCUIttED 11~. rLACi OF INJURY (aF. ia ar ~be~t tlf. WF{HlE DID C'wt~G Q~-
wr~. at o xot wLii. o I r.~.. raem.s..a.w .Ro. w~w uuuar occu~T ~ /y~
Worlc ae Weck -1 CA ~ ~-!*t W
~ I hsssby esrti~y that I ate ed tlu dtcsaced fsom.......... . 1..», to.....»....».. ..X. ...»..,19.. thot I saw tt.e
dsceassd divs on.........». ~9...~~a~d that dsoth occurrsd at............m., f
tom tlu causss and on ths dats stoted abovc.
t~a. uCW?TUt~ (De~ni .r a4) ur. ADDL~S : i~e. a1TE ucNED
William P. Simmonds I~ID Glens Aalls N Y 21 ig 6:'
21a. KACE OF W W1t, C~f WITION Ol RE1WYAl 2A. LOCATION (Cit~. Twn M Gwf? ad Sfah) ~Ic. DATE OF ~URIAL
Glens Falls Cemetery Glens Pails, N. Y. ~~~~~~/a"~
73a. SIGNA7YtE OF YNOERTAKE~ ~KISTRI?TION NO. 3i~. AOD~ESS OF YNDEtTAKER
James S. Potter A 03550 Glens Palls N. Y, ~
lsc. NAME OF ~TAlLIiHMHiT RtCISTRAiION ti0. ' 2H. pAT@ FfLiD tY LOCwI REG. riY. tICNATY~t Of RE+CIfTRAR
Potter Funerai Servi 1 22 67 Beverl W nn _
Burial aar ~ Pamit iuued by.» .......~.~X.~.X:a.Y ..~.....~9~Y.~i~ Date of iss~e.:.»....»..»..».........~t.l..~r.~ ..19.....
Traavt ~
- _ ~eYn7Y AR ~...Q~N'/A Nw ~i9g
k. . ~
THIS IS TO CERTIFY THAT~THE fore oin is a true co
g 8 py o~;,a`•'r~~drd ~`on
. , ,
file in the OFFICE OF THB CITY CLERK, CITY OF GI,ENS .:j~A ~LLS.t ;~i~1,. YORK.
Lv WITNESS WHEREOF, THIS certificate haa been dulq $ignec~, 8nd~ 8ea1Qy1
. -
by the CITY CLERR, CITY OF GLEN3 FALIS, NEW YORK.
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ATE d~K1~ P~~87 C T A , NE~~~ YO~K
, 14, F;. r . , ' I 1L._?f0?MER'~ IIAIDfN NAMi - _ - - -
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