Rifenberg, Charles Form VS. ,;}. NEW YORK STATE DEPARTMENT OF HEALTH Va -y 7
OFFICIAL BURIAL (OR REMOVAL) PERMIT -
t 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 CERTIFICAT F
DEATH, LEGIBLY WRITTEN IN DU ABLE BLACK INK.
Registered No. / 0 di
��
Dist. No b 0/ County... .. ....., . Villa
Town Y�' ��E _
z.i
r (If city, give scree ddress)
Nime of deceased
Se2 "��1. /// Single, married, widowed,
y�olol4� or divorced (write the word) ¢ a O 19..�:�3
Date of D th..
Age - Y rs // Months �� Da �. Birthpl ce.... � ).-c, -
Cause of Death v -1 .
Certificate was si /�`�, by ir(-4-,-j� , M.D.
Address..!.. .
Place of Bin'al (or 'emovai) � �^
(If body is to be tem :ly held, fill in space later)/
Cemetery.. .... ii r. • Date of Burial ikeil Z 1"-3 19..T
(If body is to be t- porarily 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 accepted the same for regi do , ave recorded it in my Local Record with the above stated Registered
Number, a on the er _ BY RANT A PERMIG T��
to )/�
e) real)
the to hold temporarily an th ody.
(LT ertaker or person having charga pf,gorpse) (In ov ,or otherwl aisno [state how
Dated. 43 3 19., (Signed) C.r... ....
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 req iced.
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Form VS 67.
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
rIySee 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
Charles .E.. RI f enb erg , who died in the* City
(City, Village, Town)
of Glens Falls on* March 20, 19 3 , Sex male ,
Color or race*, whit.e , Age*.. ..5.5...years, and Cause of Death* Pneumoceus
-men nF, s NOW INTERRED IN Pine View 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 trans.por.ted by
motor hearse for interment at P • i • (Go.d.'..s..Acre...Geme.tery)
(State fully the disposition to be made of body) (Name of plac comet
on May 19 , 1943
(Signature of undertaker)
Dated Ma.r.ch...2.5 , 19 43 Address...22.1..GI..en..St.. ,....G.lens...Fa.]1.s,. N.Y.
License No.......5.3.0.2
APPROVAL OF HEALTH OFFICER
Dist. No
I HEREBY APPROVE above Request and recom lend that Permission be granted.
(Signa),;re of Health Officer) /2".Dated / d-, 19.7t
r gInstructions 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 (*).
The Disinterment blank should be filed and carefully preserved in your office.