Mc Innes, Hugh - NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t " 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 Registered No. /
Dist. No. SL.S County /1"cr "-•'•-, or City g. �s
(If city, gtve trees address)
Name of deceased akik '1'"1/4,t Veteran ev\-----
(If veteran, give name of War)
Single, married, widowed,
Sex tiv\ or divorced (write the word) ) Date of Death .3 -(4- 19 Y..
Age (-. 3 Years Months Days Birthplace f -
Cause of Death 6--k .- a..-^*-e_ .
Certificate was signed by S / ..9 M.D.lam, .
Address S)- C dT --,2-e.„ .-e-‘
Place of Burial (or Removal) 6 v._o.;..— 71 e-..-`j C,
(If body is to be temporarily held,.(itl in space law)
Cemetery O & y r Date of Burial 3-( L 19 "7.
(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 Cam" "^..-Q D• ( 3 e -N-�.a /'r .,_ 4 t:d;2
(Name) (Address)
the .,t-- 3 to hold temporarily and ...,---AN.-- the body
(Undertaker or person having charge of corpse) (Inter, remove or otherwise dispose of (state how))
Dated `>" r,i— 19 '1'-f (Signed) 8-. ---AL,0
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) (A2-248)
r- ,.
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 typewrite, write legibly all
entries
permanent
l
e black
ink. Signatures should be legible. is a permanent record. When data cannot be obtained, write "UNKNOWN"
in applicable spaces.
I hereby request permission to disinter the dead body of:
Male Age(yrs.)
eas
Hugh Date
of Dec
MClnnes 0 Female 63
Place of Death (indicate .,hether city, village or town) of Death Cause of Death
8 Cronin Rd Twn Queensbury, NY 3-1 -?y Asphyxiation ,
Location (city,town or county) Is body to be transported by common carrier?
Cemetery now interred �.o 0 yes qt No
Pine View Cem. Vault Twn Queensburv, N.Y.
State fully the final disposition to be made of body.
To be intered
( ���7
(;ante of place or cemetery for final disposition Date of final disposition
20, l`? f
Highplanes Cemetery, Oakdale, MassApril
,Firm Name Reg. No. Address "l�-
Potte Funeral Service 101cY7N 13(, Warren Street 1 ensFalls,
Reg.No. psfe ,-
9lgnattae 'uneral Direct or d rt o11,162' ' April 19, 1971+
•
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter X111, 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 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.
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