Mc Carthy, Emily } NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rgr 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.
//� � Town, Village x Registered No.
Dist. No. 0 / County L4.) :3r.) ,1 or City 1
(If city, give street address)
n
Name of deceased /22,;/47 ram-f --& Veteran
(If veteran, give name of War)
Single, married, widowed, a
SexS, t or divorced (write the word) / K-F Date of Death /' 7-23 19
Age r c lie .Years / `7 "1 L Months Days Birthplace....... :%tl..?rate)Cause of Deati /--gym-e-t �.
Certificate was signed by iO ` ... M.D.
Address - a ' �
Place of Burial (or Re oval) '. d
(If body is to be temp ar ly eld, iil 1 in spa lat )
Cemetery -�-�zrK uJ Ce-m `{ Date of Burial ✓- :?. ..-7 ' 19
(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
to .i..sGC 4y?% g n*, /(Name) (Address)
the ?:I.. to hold temporarily and ... the body
(Undertaker or person having charge of cor se) Inte , remove, or oc rs �_is'f se of (state how))
Dated /._ 19 ...7 - (Signed) �'�f -+
" isocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t ny part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Per it (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
9 ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was 1974
(Interment or-C tron)'
(Name of Cemetery, C'remasari te.)
21
Section I,: t C-/'7—Lot No. Cz avA/No t-c,�/'
.
(Signed) L,. �.� C � •2 2�
(Person in Charge)
Address ',�-yk. L C-- ---
ti it 1�� , ,
Person in charge must return this Permit to thestrar
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.
Nla
Form VS-67 (rev. 7/63)
NEW YORK STATE DEPARTMENT OF HEALTH
Office 3f Vital Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
In completing this form, please typewrite, band-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 Deceas d � 1y /� E Male Age(yrs.)
I)/ 1Jas1� �"U. cda 2-Female It)Place of r'eath (indicate
dicate whether city,vill e or to wail) Date of Death Cause of Death
eii'Y t iChs I 5, AJ y /AZO3 Cor®n61r
r etery now intered Location (city,town or county) Is body to be transported by common carrier?
�� /,O �� ,,J{'' L Ny/Y it Yes 'No
fI h c- I iCty eromC(rli I'a[+sl� ILIA, tCgj b-1✓` i4
state fully the final disposition to be made of body.
lU Le Iiifved.
hatae of place or cemetery for fii al disposition / Date of final disposition
2ace
f ter C-1"ht'G 1 Cy° e)144N. Y✓.e t.f.5 r` _/•�I ry •
Ne. ! / Reg. �, AdHress r.
P& % l S Wee 7`-( /36 V viol Si A—,.s Re 4"Y
Signs , of Funeral ire or r 'J de )leg.46 ^ Date jb etz3
APPROVAL OF HEALTH OFFICER
I hereby approve the above request and recommend that permission be granted.
Oita. No. yignature o Officer Date
) S /7?
!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.
4 Ary