Delsignore, Gene NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. �7�
Town, Vi ipst g d No.
Dist. No..cGGi .county l.f00. or,City.. `
(If city, iv 'street addr
g-s
Name of deceased ... rk.9--' ... Veteran -0 11/
(If veteran, give name of War)
Single, married, widowe , '
Sex '2, or divorced (write the word) . �� Date of Dea 3 19 .3 ...
Age (( ars .Mo Days Birthplace �Cl
Cause of Death ..... .. )
Certificate was///signed by M.D.
i.:. ... .. � M.D.
Address ,,,,5�2..... l�i.>�j.�..�. ...,.... .... `
Place of ri l (or oval .... /q• �)1,Q'k.'- �/
(If body i. to tempo a ily he d f 11 n s I.
Cemete {er...R .,Lr<Zt' Date of Burial 3— c2 07 19?c
(If body is to be temporarily held, file space later
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same kppearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUI ED BY LAW, I have accepted the same for registra-
tion, h ve recorded it in my ocal Record •ith the above stated Regi tered N ber, and n the iasis thereof I HEREBY GRANT A
PE IT 2'-i-j2,.
to ��/(Name) i .. ./ ( dares')the ..... .. to hold temporarily an .... .. .. the body
g charge (In remove, or oche wise .spose of (state how))
( n ertaker r per,�,o avin of r se)
Dated ~c 19 . p� (Signed)
21.1kri Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to part of t..e State (subject to local cemetery or
other regulations), unless removal is by common corrier, in which case a Transit Permit(VS 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
(v
K
/
Date of " " `'` , ,i • ` /was /2/ �19 7 <<
(Interment or-Cremation)
-/ ( (. < //
(Name of Cemetery, Crtrraataciu ,-etc_)
i (/ _ ( if__ ( <// I
Section Lot No./ i/ ,) Grave No.
(Signed) ,c i, i ((-11( , , ,
\\ (Person in Charge)
Address // / z, `!
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.
r ti
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, 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 of Deceased Male Age(yrs.)
Gene F. DelSignore Female ''Cause
59
Place of Death (indicate .whether city, village or town) Date of Death Cause of Death
City of Glens Falls, New York 3/26/74 Cancer
Location (city,town or county) Is body to be transported by common carrier?
Cemetery now interred � � yes Et No
Pine View Vault Town of Queensbury, N.Y.
State fully the final disposition to be made of body.
BURIAL - MAY MEMORIAL CEMETERY, HAGUE, NEW YORK
IDate of final disposition
tCaNe of place or cemetery for final disposition I
May Memorial Cemetery, Hague N.Y. 5/3/74
Firm Name Reg. No. Address
Reg Denny, nc. 2883 Quaker Rd. , Glens Falls, N.Y. 12801
91gna a f'u Pirecfor r Un rt Reg. To. Date r 04794 5/2/74
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.