Wallace, Ruth NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(a' 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, Villag Registered No. //:?
Dist. No. .t` Q?....^...0 / County /arva—et-- or City .-... ?Z--e- 6Z &-Z
(If city, give street address)
Name of deceased •�f 4 f /. 'Zee-2- Veteran
(If veteran, give name of War)
Sin e, married, widowed,
Sex Z -c-(G, or 'vorced (write the word) /, /l�?.ZzLee/ Date of Death ..,, A=� 19 .70
Age Sf.. Years Months Days Birthplace 1,• x.•— 1 •-t4 -
Cause of Death cd ,.•,t - - , /i ��,__';1.u_z�A.--, -..-
Certificate was signed by ..f......�' �;(-c.. ' ...". ` L) M.D.
Address J...r . G.42.. .. - 4)2` `f .
Place of Bun or Removal :2 7,..--Y 'ZJ ;. cP. - ,,. (/
(If body is t e t mporarily held, fill in space er) ✓✓✓ / j
Cemetery .. .-e:1(1.,e .-'V .7-44.� .4?— -. /e/ -- Date of Burial ,.3��/ 19� )
(If body is to 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, aqd on the basis there f I HEREBY GRANT A
PERM 1
to .. .... X-6,U /?.lr:l •1 - �/i �� '-✓ �,.�-o eLr> `.';�'
ame) . (A" ddress)
the 'e r.,Cez-442g;-t,l to hold temporarily and ... - �c'C ? the body
(Undertake person having charge of corpse) p y
Dated 4�q�,_� 7 0 (Int r emove, titherw` di o of (state how))
'JJ.0 t.tI(.- 2 19 .... G (Signed) /�i• ��[Cr
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. 8/63) (9A2-205) •.' '.0
3 ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
e CREMATIONS ARE MADE
(--;-4.,Z':---- ...,1
Date of "rl *- was /14'1-/// 19/ v(Interment or..Gret.....i.,,.)-
E' tL'
(Name of Cemetery, C ,
Section Lot Grave No.
/?
(Signed) /1--'11 .4 't --��
(Person in Charge)
Address 2// -6.--"--4 4.-- ----C-A-‹
-j7 --F.�
Person in charge must return th' Permit tcl the Re ' trar
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.
--a
Form VS-67 (rev. 7763)
NEW YORK STATE DEPARTMENT OF HEALTH
Office of Vital 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 EJ Male 'Age(yrs..)
Ruth J. ,Tallace female 85 Yrs.
Place of Death (indicate .whether city,village or town) Date of Death Cause of Death
Glens Falls, New York 3-8-70
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pineview Cemetery Vault Town of Queensbury 0 yes qxrlo
State fully the final disposition to be made of body.
Burial
Nettle of place or cemetery for final disposition Date of final disposition
Schroon Lake Cemetery May 19, 1970 .
Firm Name Reg.No. Address
Re?an ? nn ;FLneral Home D-3081 341 Glen St. , Glens Falls, N.Y. 12801
1Signature of l 'ne tor r Inde er Reg. No. Date
J03484 May 15, 1970
APPROVAL OF HEALTH OFFICER
I hereby approve the above request and recommend that permission be granted.
Dist. No. Signature of Health Officer Date
!INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter X►II, 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. Tbis form should be filed and carefully preserved in your office.