Herrick, Bessie i , NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, 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.
/� I Town, Village Registered
Dist. No. �S �/ Count ) or City.... ....... .
(If city, give street address)
Name of deceased _yy .r.... eteran
(If veteran, give name of War)
Single, marri , widowed,
Sex .,.•• or divorced (write the word) Date of Death ...... 6 19 73
Age )92.....Years onths D s ' hplgc
Cause of Death
Certificate was signed byC(i/4"--4 , . ...... . Dit_e7M.D.
Addressje;
Place of Burial (or Removal) .... .
i
(If body is to bet rartly_he , filf pace ter)
Cemetery .. Date of Burial ,7i 19 73
(If body is to be mporar eld, fill in space later)
The CERTIFICATE OF DEATH containing the above stated articulars, 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, hav ecorded it in y Local Record a•' h the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
P E R /� t
to !j 6CJ��t G�
re I()1) -
.
(N Aaress
the to hold temporarily and the a.dy
(Une14cer or person hav ng charge of cor )
Dated — 19 (In remove, of e e d' ose of (state how))
7 7 (Signed)
ft cal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to 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) (A2-248)
.4 ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Ai
1 C � �
Date of �'� 2 r t '"` was ' I9
(Interment or Erema-40n)
Z ic i—Z ZL �
(Name of Cemetery, Crerna-vatic.).._—
Section CC� Lot No. / Grave No.
\(\--It
(. ' ..(7- .7-((--/C) r ic ,
(Person in Charge)
Address e 5 /`— ( L t z L_
4
P son in charge must return th sPerrmit
g C� l
gto 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.
//
Form VS-67 (rev. 11/65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau 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 ❑Male Age(yrs.)
Bessie Y. Herr1 n'k Female 92
Place of Death (indicate whether city, village or town) Date oLDeath Cause of Death
City of Glens Falls, NY 2/6/73 C.V.A.
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Cemete). Town of Queensbury, N.Y. ❑ Yes No
State fully the final disposition to be made of body.
To be Intered
Name of place or cemetery for final iilapositlon Date of n disppgaltio
Leggett Cemetery , Chedtertown. N.11 r 7
Firm Name Reg. No. Address. "
Pott= rer': Fueral Se ce 0197 . 136 Warren St. Glens Falls N.Y
;Slgnat Funeral Dire or or/)n edgk Reg, Ke. Date -
e � c?l�)�()2 5/-/ 73
•
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. 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.
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