Nichols, Elisher r- 111 I`. 61. 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. Registered No.
Town
Dist. No. �3Z Count � z.... Village
r Ci (If city, give street address)
Name of deceased .,-
���� �_ lag , arried, widowed, �� -
Sex*7 . ...Color�'�"""`t�- d rced (wrireword' !: Date o �� 19.
Age Gt Ye rs. M t s...,,1 Da -s Birthplace. .. .. ..,."..'"f.' '
Cause of Death.... '
Certificate was signed b M.D.
Address. .. . 02-sq,...
Place of Burial (or Removal)..( R- �- Z �rG - � ..,..
(If body Is to be temporarily held,fill in space later)
Cemetery Date of Burial . . .. 191‘2
(If body is to be temporarily held, till in space later)
The Certificate of Death containing the above stated particulars, having been esented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the e for r 'stration, have recorded it in my Local Record with the above stated Registered
NujoIf- , n nth the f I H REBY GRANT A PEr9"...g4.1. Q .
tow -9-r--7 :
ame) / (Addre s)
the... .. to hold tenlpor ray/and '�"`.-0', .... .. the body.
dertaker or peon having charge Acorpse) (Inter, remov s€ ells,' state bow])
Dated.... . . I.-- 19...T.. (Signed)... . ':
Local Registrar
is Permit is sufficient for the Removal (and Interment Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common ca ier, in which case a Transit Permit (VS No. 62) is required.
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Form VS 67. P
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
rie 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.
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
El:i.sher- James. .Njch•ol.a , who died in the* Tovm
(City, Village, Town)
of Bolton , N. Y. on*. ...J=)..nu ...'y.. , Sex Male....,
Color or race* White *.., .... Death* T.
Age .� years, and Cause of ry�hr-.cn.� ti.,, m o c a.rd i t i..
NOW INTERRED IN Pine V1e?"d Cemetery Vault
(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.tr. .n.s.r e.r-re.d by motc
hearse..for...bur.:I.al at Adi rondack.r..i�....Y-
(State fully the disposition to be made of body) (Name of place or!.etery
(Signature of undertaker) Cc- "4/ J. ...- . . Ce,
Dated May...1., 19 ..4.2 Address ...22..1 .-;�.1 e. .. t...,--. .] ens..x'a.11s.,- N. Y.
License No. 530.2
APPROVAL OF HEALTH OFFICER
Dist. No...,/�
I IIEREBY APPROVE above Request nd recommend that Permission be granted.
(Signat e of Health Officer)
Dated.... .... .... . . 19'1-V I
Instructions to Local Registrar: Fill out (a) Transit Permit for bodies trans-
ported by Common Carrier or (b) ordinary Offical 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 (4).
The Disinterment blank should be filed and carefully preserved ;-