Hull, Elizabeth T .,
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.
Town, Village Registered No. G > ,l Dist. No. 6-6 o.../ County J h.e,,,.) or City 2/ 4,,i
(If city, give street address)
Name of deceased 92C r1.....�.1 s4.-Le______ Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex ....or divorced (write the word) ..... ..... to Q._Date of Death ...../.. ..-. .1 19 ...7. .
Age ).. Ye rs Month Days Birthplace
Cause of Death ........rr ..
Certificate was signed by . U c.' 12
..... ... M.D.
Address2ca-�->
Place of Burial (or Removal) 7-.L------1;---i ,.. ,sa ,. .
(If body is to be temzp rarilyy1�hheld, (i in spat later
Cemetery #.' ,.L1i. .rt1- Date of Burial /— V- ,Z,&" 19
(If body is to he temporarily held, fill in space lat r)
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 nave 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 II) . ....„,_e_
to
(Name) )( dress)
the to hold temporarily an a � the body
(Undertaker or person having charge of corpse) (Inter remove,i or, otherwise 'spose of (state how))
Dated 1— -,3 19/7.5; (Signed) . 4) h•r... R ,_
Locr..Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t..= 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.
FOR34 VS. Si. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
A OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of d?"74:
C--)1,12 W was /A 19 7(5.
(Interment or C3tttaeion)-
(Name of Cemetery,<4e\a'r' ,m,
efy
Section r Lot No._ GravCf No.
(Sired
(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.
g
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.S` County or City
� pp (If city, give street address)
Name of deceased i( 1✓"- t Veteran
(If veteran, give name of War)
Single, married, widowed,Sex or divorced (write the word) Date of Death ( 1 -3/ 19 .2..Y..
Age '..14F— Years .Months Days Birthplace
Cause of Death C /1'
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held, (ifl.in space lat r)
Cemetery ,..arg D`— Date of Burial 3'(`f 19 ")
(If body is to he temporarily held i 1 in a la
The CERTIFICATE OF DEAT ntaini t e above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPL TE RECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my L a Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to C ?�,--.y..�- Low-- ( � t ,,,� i r h�. _��-
(Name) (Address) .'
the . to hold temporarily and .,..- the body
Undertaker r person avin Q l charge of corpse) (Inter, remov or otherwise dispose of (state how))
D ted
` (Signed)
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)
-
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was5/7414/9 74-----
(Interment or
(Name of Cemetery, C
Section Lot No. Grave No.
(Signe(1) -
(Person in Charge)
25--74ZAddress j E< 40.7(
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) 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 retumof 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.
t- 'i
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 ar sad L// Male0
Age(yrs•)
l 17.11 !A$- At � . I. 0 Female
Place of Death (indicate whether city, villa,.e or town) Date of Death Cause of Death
Ljc ) 4 ich s .; fizz Al y r. /3//7't c A
C eter nowp/nterred Loc-c ton (ci y,town or county) Is body to be transported by common carrier?
din / 0 Yes No
i �/ 1 Y.'faLC:�. 1r yC t� /Idh +tee k 1/ / N
State fully the final disposition to be made of body. r
t;ad�,Le of plat or cemetery for fin 1 disposition
p Date of fine disposit{ton
3
--y-i en 4S (.._r 1.,v1-f ti-ily i i WO 0)<r4i L
II
Fi i3aa Reg. No. 'Address ress , / ' f
isignat e f 1'unerel.Director o {In rta er - — Reg. No. Date r
s
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.
0