Chadwick, Robert NEW YORK STATE DEPARTMENT OF HEALTH
w OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom' 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. (7
Dist. No. 0 ( County or City �.-G= „.. _ sL-s, :,______
(If city, give street address)
Name of deceased �Nr-.z....1 .-.,_14,—' Veteran
(If veteran, give name of War)
Single, married, widowed, -
Sex or divorced (write the word) .... Date of Death -N L. - 19 .1..0
Age 4"9 Years .Months Days Birthplace h
Cause of Death ....1.a.,�S).- ..„
Certificate was signed by . . , M.D.
Address . - _ _ _-- _._.-
Place of Burial (or Removal) -��
(If body is to he temporarily held, fill in space later)
Cemetery `. k-...-.._...1 - - ;.., - `' Date of Burial a -\'I- 19 'To
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above t ted 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 1;
to V
... .�- ' .—ice. .., •,ram- �" 'r--Q--_ )3 ca c..;...;. .,,-
(Name) (Address)
the •V to hold temporarily and ..-s.-,-.-. L,_... the body
Dated(Undertaker or person having charge of corpse) (Inter, remo e, or otherwise dispose of fate how))
19 )O (Signed)
,•- R tcar• """
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of el e State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. .2) is required.
FORM VS. 61. (REV. 6/63) (9A2-205) Q
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
cfr
Date o � �� was / - 19/74'
(Interment or E-feana,thri
(Name of Cemetery, f.—t‘Nri,,T. etc.) „_.
Section ) `2eZ✓/Lot No. Grave No.
(Signed) -
( erson in Charge)
� ��Address �
Person in charge must return this Permit to the Registrar
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
Egr 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.
C Town, Village Registered No.
.-
Dist. No. ...3 W , [ County 7 - --... or City 9/-... "n j ti
(If city, giC4 street address)
Name of deceased (2 rt- ` (ALL_ .. - Veteran
(If veteran, give name of War)
Single, married, widowed, o
Sex °)`� or divorced (write the word) Dat of Death .� ( 6 19
Age 1-7 Years .Months Days hplace
Cause of Death
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body is to bet mporarily held, ill in ace later)
Cemetery ''v"v ` -+-•'- Date of Burial y—(Le 197 0
(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 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 j d" 7r 5-- SJI-v,--e- ( -)' ^✓ry►.t,,y .1'i- 1-2 .-L -aILi 14....
(Name) (Address)
the to hold temporarily and .t? ^• Y the body
(Undertaker person having charge of corpse) (Inter, remove, or othe wise dispose of (state how))
Dated (1/4. 19 ' ° (Signed) 64-e - 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)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
} v CREMATIONS ARE MADE
Date of 9w-eas ¼619/'2
(Interment or C--wt;042,).._.5h-527
(Name of Cemetery, Cre4 at i.om, etc.
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address
Person in charge must return this Permit to the Registrar
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.
Form VS-67 (rev. 7/63)
r `. .4 �°` NEW YORK STATE DEPARTMENT OF HEALTH
y- Office of Vital Records
ti
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 )Male Age(yrs.)
Robert Chadwick ❑ Female 87
Place of Death(indicate whether city, village or town) Date of Death Cause of Death
Glens Falls, New York FAb_1 h,7C1 Fnenronin
Cemetery now interred Location(city,town or county) Is body to be transported by�ommon carrier?
]
Pie View cep. Town of Cueensht�ry im 0 yes No
State fully the final disposition to be made of body.
To be inhered
Nettle of place or cemetery for final disposition
Date of final disposition
bit N .man C erne to ry : Tern of Que ensbury tl..61'7O.
Firm \♦amen Reg.No. Address
Potte ' eral Serv' D1803 136 Warren St. Glens Falls. EY
1Signature 'uneral.'irector nde ak Reg. No. Date
C13232 1/5/7.
APPROVAL OF HEALTH OFFICER
i hereby approve the above request and recommend that permission be granted.
Date
l)ist. No. Fignature of Health Officer '1 /6/ /)
!INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter XIII, 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.