Chase, Harry Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIF� DOF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. DD..
Dist. N 0/ County /4 Vt1T ge... ... ...�'',.r/' -.
. 'ty / /(If city, give a eet address)
Name of deceased
. Singl , married, widow C ��
ex Colo. o divorced (write the word) Date of Dg�th 9•
Age 0.co
Years /O Months.... 9 Days C�place .. G
Cause of Death 7
Certificate was signe by74."-te,c, ,
M.I .
Address i'_er 7"i`.r.
Place of Burial (or ,va,l) /
(If body is to be tempo
+- sp c er)
Cemetery � � Date of Burial , y,C 19.50
(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 exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce• the same ••r re • tr- r.n, have recorded it in my L ord with the above stated Registered
Number, a � bi'. th / i E•EBYGRANT A PERMIT
to
the AK �!! to hold temporarily an th ody.
(an. a + :-r or pers having charge o rpse) (I ,or oth a dis a to ho
Dated 4 .+ ....! 19.�i (Signed) ��
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subje 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 67.
NEW YORK
STATE DEPARTMENT OF HEALTH
ALEANY
UNDERTAKER' S REQUEST TO DIS INTER BODY
rSee 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 AL WAYS 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
Rarry Rutherford Chase who°died in the* CI ty
(City, Village, Town)
of Glens.. ell .:...:...: on* Nov.....2g.,...194.3 , Sex ws Le...,
Color or race* white Age*...:_..6.5:years, and Cause of Death* Coronary trombos s .
NOW INTERRED IN...Ein.e..V.i ew..0 emet.ery..vault
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
(State fully the disposition to be made of boar) at (Name of.place or eemetery)
(b) The body is NOT to be transported by Common. Carrier but is to be trens,po.rt.ed by
. . ...:.wotor..hearse for .burial.. /. .at Glens. Fa : emete.ry--w to-bsmade of br) --- --
`1
(Signature of undertaker) ue'-
Dated April...19th, 19. . 4. Address 221..Clea .S.t...,..,G.1 en.s...Fa.11s,, N.Y.
• License No..... 93
APPROVAL OF HEALTH OFFICER
Dist. No. ✓-S
-7
I HEREBY APPROVE above Requestandmr n th Pe o be granted.
(Si r of Health Officer)
Dated te /r 19.1/14
W"Instructions to Local Registrar: Fill out (a) T ' 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 (*).
The Disinterment blank should be filed and carefully prerved in your office.