Lapham, Minnie Form VS.CI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VEr 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....>..3—
56J1 •�rarren Town Glens Falls New York
Dist. No County Village t
or City (If city,give street address)
Name of deceased ..:innie ._ aa:1i
Single, married, widowed,
Sex....1'. Iti Color „i:4)...uE..or divorced (write the word).. 1.1.0.0.W.e.(i Date of DeathMs.r.Ch...1.7 19..4
Age 7 Years Months..;"k Days Birthplace r QV; tinrl,...kl. lY... ..UX'
Cause of Death. X. ,Qr.3.a....0.1:...c. . 1111 4l)1.e; .1'--1
Certificate was signed by a 1.. .,1:.7,am, i+ . 1:-'A wv e rl M.D.
Address c.ieris Fails, Mew York
Place of Burial (or Removal) Glens Falls , New 1ori
(If body is to be temporarily held,fill in space later)
Cemetery :..:.:J s.....la. sY...3Tc.ilii..t Date of Burial C.r.Cxl...i 9., 19 4
(If body is to be temporarily held,fill in space later)
The Certificate of Death cone^.ining the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he 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, then basis thereof I HEREBY GRANT A PERMIT
to c3 Q i J`t t,?T L`-' :V r 'P a+...lcl Y.s..,....G.LQ..'a z...l;.111.:..s.,....J..Y,
tin er taiSTIlme) (Address)
the to hold temporarily and.... I:].te.• the body.
(Undertaker or person having charge of corpse) er, remove,o tt is snose of [state how])
Dated •uaT i;il i 19 40. (Signed) :1. exist '
Local egistr
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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Form VS No.67. 9-16-30-5000 (17-1827)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER' S REQUEST TO DISINTER BODY
,' t . '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
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
lanni e ,t. La liam , who died in the * Cr Y
(City,Village,Town)
of Glens Falls on * March 17,- 1940 , Sex, Female
Color or race* White , Age* 70 years, and Cause of Death*
Myocarditis & Anaemia NOW INTERRED IN__P_ ne _1I,i.m ._3Ia .t
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
Interment at West Fort Ann Cemetery
(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
---- t
(State fully the disposition to be made of body) (Name of place or cemetery)
1
(Signature of undertaker) .e.e _C _ ri-
Dated May 4tJ, i9 40 Address___7'' w 0 V
License No.____l__3
APPROVAL OF HEA OFFICER
Dist. No.
I HEREBY APPROVE above Request a e that '•rmission be gran .
(Signature of Health Officer) ,J /c- ---
Dated C/I/1.7 149
; _ =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.