Williams, Eugenie • Pavan Vs:AIL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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. /I
Town -� - n
Dist. No 4-tat County G��r -`t• Village 3 7 v,.��. 1
Of Ci (If city,give street address)
•Nime of deceased G�/ � z.-4
Sex ,� (f aY Si widowed, ,B9 • !Z J3
''Color or divorced (write the word) G`� Date of Death 19.f
Age ?/ Year `7� Months l D Blrt lace i.e) �"-
Cause of Death �J 7-- - d _ C'� - c,C
Certificate was signed� �"`����,• �� M M.D.s1�
Address •
Place of Burial (or R val) reto
(If body is to be tempoeld„fill in a later) ._.— (/
Cemetery � I, N-Q... ....C.P„�,1" l� Date f Burial J S 19.T3
(If body is to be temp ari y held, fill in space later) '
The Certificate of Death containing the above stated particulars, having been pres rated to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce. ed the same for registration, have recorded it in my Local Record with the above stated Registered
Nto
umber, : ;r/ th -*". • S HE'EBY GRANT A PERN�,IT Q /� j , /'�''S�`G
�� i// y i vb/ /6KGr144 Ll.>e
dress)
the � .... ...... ........... .. to hold temporarily an},lr� ,f� ,eo..,. the body.
( deri�}}ke��r or personhaving charg��6 corpse) - / 'I ve,or off.. i no e to how])
Dated. all. , 19.f`y . (Signed) %/Y//
Local Registrar
ThisPermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the to (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS N 62) is required.
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Form VS 67.
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER 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.
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
Mrs... .Eugen.L.e..1 a1.1.i.am,s , who died in the* City
(City, Village, Town)
of Glens. Fans on* Ja-n.....12.,...1943...., Sex....F.emale..,
Color or race* whi.tY , Age ..7.1 .years, and Cause of Death*General toxemia,
starv=�tAon, chronic Rast trit1s.
NOW INTERRED IN....P.ine. .Vi w...Cemet.ery...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)
..r. Th bodrrm n yrtr-x�3e
(b) e y is NOT to-be transported by Common Carrier but is to be...tr.ar:�.por.t.ed by --
.. ..mo.to.r..hearse..far...inte.rm.= % at Evers en Cemetery„ Keesville, N. Y.
(State fully the disposition to be made o' •.. ) of place or cemetery)
on May ,Oth, 194.3.
(Signature of undertaker).. . v , la".Dated - ' . r. Addres . ,4:.��rareh �, � 1;,.3. _ .:Glen...St. , sl.er>.s...-ffa11.s.,..N. Y.
License No. 4.4.q.-;
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Reques and r commend thjt P mission e granted.
(Signature of Health Officer) f`, .. ... `„
Dated 4 / /d-19.4i.
Instructions to Local Registrar: Fill out (a) Transit ermit 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 preserved in your office.