Wright, Jennie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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. Re re d No. /07
�' Town Villae
Dist. Nov 6d/ County or City
, g
y
vv _C� - (I( city, give street address)
Name of deceased Veteran
(If veteran give name of War)
Qn Single, married, widowed,
Sex or divorced (write the word) ... Date of Death .. �I 19 .7...
Age c Years .Months Da Birthplace
Cause of Death
Certificate was signed by Wei 5efie_e_,=, c::: 1 )-7 ... M.D.
Address
...... ... ...
Place of Burial (or Removal
(If body is to be orariIy he p ftl in p er
Cemetery 4 LI...Q.�,t,.� C/ Date of Burial 0—.( 1973
(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 SAT SFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav rec rded it in my L Record with the ab a stated Registered Number, and on the basis thereof I HEREBY GR NT A
PERMI
(N �ressS
the to hold temporarily and the body
(Undertaker or perso avin charge of corps (Inter, remove, or otherwise di pose-of (state how))
Dated �/ 19 .7..... .... (Signed) Ni^
This Permit is s fficient for the Removal (and Interment or Cremation)of a body to a - art' h 91001,1L a local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
i
T—__
Date of t L C k I e.;-kc. as 7 ' 19 7 -
(Interment or C cinn)
(Name of Cemetery, )
Section Lot Not •'Z'��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. 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.
1 hereby request permission to disinter the dead body of:
Name of Deceased • 0 Male Age(yrs.)
Jennie I`_ Wright ct Female 85
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City of Glens Falls, N.Y. 2/18/73 Coronary Occlusion
Cemetery now interred Location (city,town or county) s Is body to be transported by common carrier?
Pine', Viohw Cuterr Town of Queenshnry, N."' ❑ Yee No
State fully the final disposition to lye made of body.
to be intered
Name of place or cemetery for final disposition. .0 Date of final disposition',
FQ,rest Hills CAmrtf:Ary, .Tn Ica Plai miss June 12, 1971
Firm Name Reg. No. Address
Potted eral s n1971! 13A Warr��4,'j'R� St. ale Fall°, '_y.
'Signature fnerIyector or nd R er '� ` v "2 rtez:(71,2)
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, Jill out ordinary Officjal 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.
r - JO