Jenkins, Ida NEW YORK STATE DEPARTMENT OF HEALTH
r OFFICIAL BURIAL (OR REMOVAL) PERMIT
s`Thu Permit can be signed only by the Local Registrar (Deputy or Subreginrar) 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, LyGZILX.WRITTEN IN DURABLE BLACK INK.
Dist. Nos,
7 Registered No..-.w._._..._....:......._._....
co ur�f!y �,IG ..... r-0-- ».__.._ ... _ _..Town
Village__ _......_...-..
or City - ..._..(If
��.�i... .er�ee�.a�..e�-..
Name of deceased i -..,4 _-
-
---
M ,�,S Ingle, i led, widowed,
Se Colo divorced (write the wow
Age .„. Years.... ........... ...... ...Months......--- ..„ Days Birthplace
Cause of Death.
- Certificate was_ si. ..,0i� *- �.-
Address .i tea.
F Place of Buri or ,. .... � t... .......� r:�•.,•..�• ....._.. �..
Remov
(If body is be penrily y(lspte•~laar)
h ll
Cemetery _ --. Date of BurilEU _, 19
t (if body be temporarily held, ill 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 Number,.
and the basis thereof I HEREBY GRANT k PERMIT
Woad) ,
th . .. ...to hold temporaril and the body.
(Und or person having charge of rs) (I dispose of [sate howl)
Dated, ........,.igrar
Signed). . ...
I.oeal npi.cer
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) L requited.
o.
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Form VS. 61. 8-16.3 5-50,000 (17.1423)
NEW YORK STATE DEPARTMENT OF HEALTH -
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ill!`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. 1»..�'`� »..... Registeredre No....
Town -
County (.Y,,/J.l�°'-N-14Ze Village
r '' ���„ ..».»........»»......
If«er,live aaroet addrw)
Name of deceased ».... » »». _ -..».....».........••.».......».,.............
Single, married, wid ed,
Sex. \I Color 'a/ divorced {write t e word) Date of Death-.-- . ». .19»`. '
p � /
Age �?.1� Years Months. »»�.c� Days Birthplace GZ - ..'"'. -, ...-
Cause-of Death . ».. ... ..»»..: .... » ...�.. » . »»»
Certificate was signed by :;...»..Ci • ».»...........».. .. »»».._........»» ..,. .».»»»..»M.D.
- Address t� � .....»....... ....»..........».......»...._...._».».....»� »
Place of Burial (or Removal) -c...i .�e �;-_ .r,�� » »» »
(If body is to be tern.'-lily hel./fill in space
Date of T.
` Z � .. 19» �O
Cemetery...»..»».....»..r ���. . . �._...
(If body is to be te./rarily held, fill in space later)
The Certificate .f 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 Number,
and o h is thereof I Fir GRANT A PERMIT
P4
." (Ad em)
the.....»..... 7Ait(..,Isi_l_ame)
to hold temporarily ..». the body.
Uncle er or person}living charge of co se) (Inter, remove, or ise se of [ )
Dated ..ah !' 19"o (Signed) ... . . ......!/_....».... - ...._ _.._.»....... .»._.»..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cre=-�Ation) of a body to any part of the State (subject to local cemetery r
or other regulations), unless removal is brisLinon carrier, in whie rransit Permit (VS No. 62) is required. i A
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Form VS 67. 11-20-35.5000(17.3709)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISENTER BODY
='See Special Administrative Regulation 1, subdivision 4, Relating to the Trans-
portation 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.
SER BY REQUES PERMISS TO DISI TER the dead body of
h diedin the*)' '7- , w who a �.�
(Gilt, Vi ag
of....kr4 .. .. .. * _ on*MG Sex ,
Color or race*.. .. .. . . , Age .6 l* i< :.1`., fh
..11....ye. , . Cause of eath*
NOW A�_�::_:____ N (l
(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)
-...------------(4)-- T body--is NOT to be transported by Common Carrier but is to be .. ._ . .. . A
(State fully the disposition to be made of body (Name of place or cemetery)
(Signature of undertaker) . .
JA
Dated1 . "// 194c1 Address .... 7G'� e f. ,
License No 4A:
APPROVAL OF HEALTH 0
Dist. No.
I HEREBY APPROVE above Request reco e th Per sion be granted.
(Signature of ealth Officer)
Ws....__IDated .�/ 19'frlei
InsitActions to Local Registrar: Fill out (a) Transit Permit for bodies trans-
ported by Common Carrier or (b) ordinary Of fical 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. When data can not be obtained write "Unknown" in spaces in-
dicated by (s).
The Disinterment blank should be filed and carefully preserved in your office.
c, (4?` - .
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