Morehouse, Sharlene '~. NEW,YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rge' 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
Dist. No. `' County ' - r-e
Town, Village Registered No.
C or City ` - "' )."10--
.r . (If city, give strgtka$dress)
Name of deceased J 4`sJL°--•>--k— ti`��4. "`` Veteran • 6--
(If veteran, give name of War)
Single, married, widowed,
Sex ?y, ;,y,,,,,,,-, -e, or divorced (write the word) f^-v^' ` Date of Death —4." 19 .7..I...
Age f)--- Years .Months Da s ?Birthplace '11 -
Cause of Death fr^^-. � '�L -Y" �r �+ " � a
Certificate was signed by J tl ,.--� j � M.D.
Address c.4-- "\. S ,w a-.��t.c- L,c ti'
Place of Burial (or Removal) rj y� .---,_
(If body is to be temporaril he d fi . in space I ter)
Cemetery ,Jx'i r . . —__ Date of Burial 3 ~� 19 7
(If body is to he temporarily held,' ill 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 P,
to "v"-` "- s�. •ti ( Y naves s - ,4't
Name) �/ (Address s)
the ,...)►A..-+-•- -a to hold temporarily and ,,4,.----2.,-- the body
(Undertaker or perspn having charge of corpse) (Inter, remove, or otherWse dispose of (state how))
Dated "\".�,�-4-L. 1 19 `1 ( (Signed) �..... s. k. C.l`¢
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) (6A2-205) Q
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 01✓ "7t-C was -1)14,J .2 19 7/_
(Interment or Cremation)
cr.91 , (} Jj
(Name f Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
erson in Charge)
Address
s-- adree4-4
4./ y
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.
Fopm VS 61.
4-, NEW YORK
r;" } tf STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
1'See Special Administrative Regulation I, 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
Sharlene Morehouse
who diedin the*.T.own..Q�: Q.ueensbur3
(City. Village. 'Iowa)
of Que.ensbury , Sex...F'.ema.�.e••�
Color or race*...Whi.te , Age*...12 years, and Cause of Death*
Gun Shot, Wound to Head
NOW INTERRED IN....S: .....A.1phor.aus...Cemetery
(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
Intered outh Horican Cemetery
(State fully the disposition to his made of body) (Name of place or cemetery)
}
(Signature of undertaker)
Nfay...13 ,1971 19 Addred 3 4 $a Rd ....G7,exts..
Dated '� 1 y... ,•••
License No.
APPROVAL OF HEALTH OFFICER
Dist.,No.
I HEREBY APPROVE above Request and recommend that Permission be granted.
(Signature of Health Officer) Qf
Dated /3 - 197/...
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 (s).
The Disinterment blank should be filed and carefully preserved in your office.