Leigh, Jessie Form vs. " 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 CERTICISTE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No...
�� Tnwt
Dist. No..�0l County e- Y140--- . .
. ty f çitY. ivereef address)
Name of deceased �,.. ..
Sing , married, widowed, ��
Sex Color.... or divorced (write the word Date of D--. ..19,
g . 3 ...Year= / C lb nths 7'5-Days Birthplace.. of ��
Age
*g .,4ceieree......1_41.0:.„0,40
Cause of Death ' 41'ir°417'
Certificate was signed-by ��. . e f
Address
Place of Buri or Rem. ,C.�l.>%S�
(If body is to b poraril .y ill In apace la
Cemetery... �GeI.e, G:? Date of B rial.. .... .319. ...a',
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been pre ented 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 registra on, have recorded it in my Local Record with the above stated Registered
Numbe don the sis jlyereof I E R T A PERMIT
to cy ,"..., ....
(Ad s
the to hold temporarily a ...t e body.
(LT dertaker or person havi y'a arge �vvse) ( re ova,or oth is ose of [ate w])
Dated. . ... . .. . .!H!.V..19... f..g.7 (Signed)
Local Registrar
is Permit is su cient for the Removal (and Interment or Cremation) of a body to any part of the State subject to local
cemetery or other regu aborts). 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
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY ;.
lFSee 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
Jes.si.e...C.1eiaad..Loigh , who died in the* City
(City, Village, Town)
of Glens-•- 'ans ,
Color or race* White , Age*. ...63 years, and Cause of Death* Septic toxalmia of
ki dney .
NOW INTERRED IN Pine.. View Cezme.tery..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...h.ea-r.a.e-..fox...b11r. . .._ at ioarn. •CF3mete.r r .P " a.rr, h'.•..Y_
(State fully the disposition to be made of body) e of or cem y
on May 14, 1943 /
(Signature of undertaker) , `V ' •
Dated...Mar.ch-..15, 19...4.3 Address... 221...G1.en...St...,...G7.-ens...}+'a1I.S., N.1.
License No. 5 302
APPROVAL OF HEALTH OFFICER
Dist. No
I HEREBY APPROVE above Request and rec mmend th t P mis ' be granted.
(Signature of Health Officer)
Dated... . rc.h <-9/\ 19 ..43.
Instructions to Local Registrar: Fill out (a) Tran it 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.