Washer, J Dix Form vs.al. ' i NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir 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 CERTI ICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No 1
5726 Washington Vewn
Dist. No County Village Hudson Falls.. &X.
(If city,give street address)
Name of deceased J. Dix Washer ��"ity
Single, married, widowed,
Male White Widowed Date of Death March 4, ,.19...46
Sex Color or divorced (write the word)..
Age 79 Years 5 Months la Days Birthplace Clintonville,...N...Y..... .._. ..
Cause of Death Cerebral Thrombosis - Coronary Sclerosis - Cerebrai S.clexosia...
Certificate was signed by J• Leonard Byrnes M.D.
Address Uudaon. .Falls.....N...Y.'
Place of Burial (or Removal)fill in_space later)
Falls, N,Y..
(If body is to rine radlv View vault later) M .a 7. 19...46
Cemetery {/1 J� Date of Lurial
(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 he COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to S�Wa'a Potter Glena..F.alls,..:N...Y.
(Name) (Add s)
the Undertaker to hold temporari and Pla�.e.f o...Y4 lit the body.
(Undertaker or person having charge of corpse) (luteA remov• .r ot. /^ise dispose of[state how])
Dated March f, ,, 19.4e... (Signed i ` •
""��
ocal Registrar
This Permit is sufficient for tfv. Removal (and Interment or Cremation) of a body to any part of the State (subject 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
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
Q;'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 RE UEST PERMISSION TO DISINTER the dead body 3,
.. .... . ... ..... , who died in the* e�� vac
(City, Villag , Town)
of on* . 'S<,. /9-5, -e , Sex..��1�(c c..,
Color or race* o
� - , Age* 79 years, and Cause of Death* �_� �0r.e
NOW INTERRED IN.C
.tee... .�eau— _ . . U�
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
at... .... . .�rt:z -4... �
. ...
(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
at
(State fully the disposition to be made of body) (Name of place or cemetery) -- -—
(Signature of undertaker) .. f,_.��
Dated c % ' ' 19'•/� Address..Y�.P.-/27,41-e-r-r, AZie c it t vZ ---)7
License No. /3 i
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request and recommend that Permission be granted.
A...:.G.,..;-t -4.
(Signature of1Health Officer)....1----4-e .. dP
Dated - Z. 19 564'
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 (*).
The Disinterment blank should be filed and carefully preserved in your office.