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Wing, Sanford r _�r 1 NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT Qgr 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. Town, Village Registered No. ....s� ,� Dist. No. County ''" ,'"`--- or City ci " (If citve street address) Name of deceased ) ,,,C 'V ' " Veteran �. (If veteran, give name of War) Single, married, widowed, Sex f- or divorced ^(write the word) j4- ,"L`-- Date of Death .) )-/ 19 7 Age "? ci Years .Months Days Birthplace ^- - -- C --�. Cause of Death u.^r—.^ C-0- 4n ..y 4x'3 C..4-.4-'u`.- Certificate was signed by ,.. .--, t,,- M.D. Address '? '( -,,vim.:.,.=u:--- S'1 , _., ,e '-i 4 (d. 1FY I Place of Burial (or Removal) .,._ �---e _Y (If body is to be temporarily held, fill in space later) Cemetery 'c. 4-- (' -,— { Date of Burial 3 '-.4.j 19 -7 0 (If body is to he temporarily held, fill in space later) The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra- tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A PERMIT ( ) (Address) the .. .:..Si-,/ '" to hold temporarily and the body (Undertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how)) Dated .. ,`t^-`-�-V - 19 ") ' (Signed) . .ti v . c"-t'..2 -.. Local Registrar This Permit is sufficient for the 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. FORM VS. 61• (REV. 6/63) (3A2-323) t G ENDORSEMENT OF' SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date o , . Awas ' 19 76� _ i (Interment or„Cre' ton) 1 (----j---?., ''jl..,-Q--e'/--P---e—e..-c/'N,„._, (Name of Cemetery, Croa , Prc ) Section fr/*----.4-1-'4:1- Lot Grave No. �� t (Person in Charge) /^ Address Per on in charge must return this Permit to the R istrar of his District within SEVEN (7) DAYS from above date. If no person is in charge, the FUNERAL DIRECTOR or UNDER- TAKER MUST SIGN ABOVE STATEMENT, write across the face of the Permit the words "No person in charge," and FILE PERMIT WITHIN THREE (3) DAYS with the Registrar of District in which cemetery is located. SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS violating the law relative to the return of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Registrars are required, under penalty, to report violations thereof. 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 CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town, Village ( Registered No.Dist. No. ..., \o 7 County CThrve"` (l- or City (C rr (If city, gig street address) Name of deceased �1 v-je„ - ivv).--- Veteran (If veteran, give name of War) Single, married, widowed, Sex \e- 1— or divorced (write the word) Date of Death 3 -- f 19 7 O Age 7 7 Years .Months Days Birthplace Cause of Death Certificate was signed by M.D. Address Place of Burial (or Re oval (If body is to be tempora ly h fill in space 1 ter) Cemetery Ur.-�, � Date of Burial y-7 19 7 0 (If body is to he tempor ily held, fill in space later) The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra- tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A PERMIT to Ay-, tf y ..,... P )" V ( 212= A---z 7 -I 00 ame) (Address) the to hold temporarily and A.::,--A--,r' the body (Undertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how)) Dated 7 19 ", ® (Signed) G -•Q-- , 0 C- . Local Registrar This Permit is sufficient for the 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. FORM VS. 61. (REV. 6/63) (3A2-323) r ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR , CREMATIONS ARE MADE s Date of s../ '"`' 11 41 was _ 19 7 (Interment or-FA.a a iota (Name f Cemetery, , Section Lot No. Grave No. (Signed) (Person in Charge) /"� � (Address - Person in charge must return this Permit to the RIgistrar 7 of his District within SEVEN (1) DAYS from above date. If no person is in charge, the FUNERAL DIRECTOR or UNDER- TAKER MUST SIGN ABOVE STATEMENT, write across the face of the Permit the words "No person in charge," and FILE PERMIT WITHIN THREE (3) DAYS with the Registrar of District in which cemetery is located. SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS violating the law relative to the return of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Registrars are required, under penalty, to report violations thereof. Form.VS-67 (rev. 7763) NEW YORK STATE DEPARTMENT OF HEALTH Office Df Vita! Records FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY In completing this form, please typewrite, hand-print or write legibly all entries in permanent black or blue black ink. Signatures should be legible. This is a permanent record. When data cannot be obtained, write "UNKNOWN" in applicable spaces. I hereby request permission to disinter the dead body of: Name of Deceased Sanford 7 r] Male Age(yrs.) i n Female 79 Place of Death (indicate whether city, village or town) Date of Death Cause of Death 3 Town of Queensbur y —7O , ,Y —21 y1'cemetery now interred Location (city, town or county) ils body to be transported by common carriers ___- -) Pine View (Vault) Town of Queensbury 0 Yes [ No State fully the final disposition to be made of body. Burial in Quaker Cemetery, Town of Queensbury, �`Y Nathe of place or cemetery for final disposition Date of final disposition zuaker 4-7-70 • Firm Name Reg. No. Address !Signature-,Hesa - - Be n.y T c . D30 �1 341 Olen �'t. ^7 �/ of 'une 1,Director r')ndert ker 7 t=n S "�t ] .�` V �2 j Reg. No. Date ' - ... .--- - 003484 4-7-73 i APPROVAL OF HEALTH OFFICER I hereby approve the above request and recommend that permission be granted. Dist. No. Fignat-we of Health Officer Date 'INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER: 1. See Section 13.1 (formerly Chapter III, subdivision 4) of the Sanitary Code, relating to the transportation of dead bodies by common carriers, as printed on the back of the Transit Label. 2. Permission for disinterment must always be obtained whether the body to be disinterred is to be transported by common carrier or by other means. 3. The data required concerning the decedent may be obtained from the local register or cemetery record. INSTRUCTIONS TO LOCAL REGISTRAR: 1. For bodies to be transported by common carrier, fill out Transit Permit. 2. For bodies not to be transported by common carrier, fill out ordinary Official Burial(or Removal) Permit. 3. In each case write the word "DISINTERMENT" on the Permit. 4. This form should be filed and carefully preserved in your office.