Harvey, Walter Form VS 61. 6-8.34.50,000 (17.7901)
- _ NEW YORK 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.
Dist. No 5 6..so.../... a/ Registered No..-
Town o� /�` — /f
County Villa:e V
0 ` jrk, if (If city,give street address)
Name of deceased a_ (
Sex "1ma�yy,, Single,married,widowed, nn
/ -Color b'Z 'or divorced (write the word) ate o Death `� 0--“..(..f` 19.r,3.�
Age 2 �1 Yea " /
l! Months /.l ys Birthplace •
Cause of Death - /JA
Certificate was signed by .. Zl 7-E-
......� IVI D
Address ' 7,2,Place of Burial • Removal). ?
.............. .............. . ..
(If body is to be tem/'= ily held,fill in grace 1 ter �, r
Cemetery ..e..4.4..!?,.. 6L.e... ..,6 ` G/..L�a.. ,, ::i Date of Burial — ?I:Z-(4it5
( F 19 '
(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 examina-
tion, 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/�isJ Number,
and on basis tHsreof 1, ByY RANT A PERMITli-t ti X�X�O
tot , ,
(� dd J
the ... to hold temporaril d the dy.
ertaker or per on having charge ofror ,f ,or wig isy of[state ho )
Dated f 19.:E7.!] , (Signed)... .... �_ F
Local Registrar
Thi ermit is su icient for the Removal (and Interment or Cremation) f a body any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Tr nsit Perm (VS No. 62) is required.
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Form VS No.67. 9-16-30-5000 (17-1827)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
See Rule 4, Special Administrative Rules Relating to the Transportation
of Dead Bodies by Common Carriers, as printed on the back of TRANSIT LABEL.
N. B. Permission for Disinterment must ALWAYS be obtained whether
the Body disinterred is to be transported by Common Carrier or by other means.
reriove
I HEREBY RE VEST PERMISSION TO -3I8.I 4ER. the dead body of
11 e; , who died in the * City
(City,Village,Town)
of dens Falls ?`r.' on* anuarr 17 1935 Sex, -ale
Color Color or race* 'h i t e , Age* 46 years, and Cause of Death*
7- placed
/_- NOW-ENT ERRED- IN - ine 'iew Geri. va t
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
at
(State fully the disposition to be made of body) (Name of place or cemetery)
(b) The body is NOT to be transported by Common Carrier but is to be transferred
ti _ear`st i or Uur'ia1 - at .nion Genet er y a G _'�"
(State fully the disposition to be made of body) e (Name of place or cemetery)
721,
(Signature of undertaker)
Dated -Tay 1 19 )°" _} Address Hurd son F`a 11 s,
License No.
AP ROVAL- OF HEALTH OFFICER, ,. ___ -_ ,,,,,,/°
Dist. No
I HEREBY APPROVE above Request and recommend that Permission be granted.
(Signature of Health Officer) 2Nr
Dated / -` r9
a2F-Instructions to Local Registrar: Fill out (a) Transit Permit for bodies
transported by Common Carrier or (b) ordinary Official Burial (or Removal)
Permit for bodies not to be so transported, in each case writing the word
"DISINTERMENT" on the Permit. The data required concerning the decedent
may be filled in from the local register or cemetery record, writing "Unknown"
as indicated by (*) when the data can not be obtained.
The Disinterment blank should be filed and carefully preserved in your office.
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