Osborn, Nelson a "S
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. \lC)
Town, Village Re tered No.
Dist. No. '\ County\,JC:z-- � or City &S1✓ !a 2
(If city, give street address)
Name of deceased kcci.>lQ,- .N.... C.Dy.Ps .r.s Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex 1-CX-9- or divorced (write the word) .T.i\WA9 Date of Death ..Y Q (' - 19 -15-
Age `'\ Years Months Days Birthplace
Cause of Death . W�. 1.il.exS�
Certificate was signed by e .. - i.T,l�-0- M.D.
Address G,,�,\),,.�th-1 QP� G..S2.A"ra C-- 94
Place of Burial (or Removal t.'N (,�.(.1.1�2. ^�)
(If body is to be tnporarily h , fa in sp a later)
Cemetery t'ki`(N4111-tis Date of Burial 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
PER 4IT
to .. c_ -1•-. -C)4�tY1n. A....\1-:ON1 Q-. 1 J.1� ccNs? ..,-'
(Name) (Aaaress)
the ................. ...... ' p to hold temporarily and C.-av9 , the body
(Underta person having charge of,corp ) (Inter, remove, or otherwise dispose of (state how))
Dated .s 6- r --1 19 fS� (Signed) .. .
��fff ie igt
This Permit is sufficient for the Removal (and Interment or Cremation)of a y to a f pa�t�df k, to (srar
ubject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is re uired.
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 as 719 7°5
(Interment or Cremarin..).__
(Name of Cemetery, Ctentatorinin-ete:)---- ---�
Section Lot No. Grave No.
Si ed
( gn )
(Person in Charge)
,�j
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.
.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 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 71 Deceased Male Age(yrs
Nelsen Sr Osborn 0 Female
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
alens Falls*. New ark 2/25/75' Cerebral Hemmoraae •
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Fine View Cam Vault Twln Qiieertebury, N_v, 0 Yes MI No
State fully the final disposition to be made of body.
To be interred
Fame of place or cemetery for final disposition Date of final disposition
Ainttivi 11 a CAM- Amityville, N.Y. 1/12/75
Firm Name i Reg. No. Address
Putt: Funeral er oe Ol97 ' 136. Warr n r.1 a F�l 1s �„v*
BCgnatur Funeral Director [lad ak r �' kilt-No.` Veto --- , ,, :---*.a*,,,,__,
") , c —, Oil It 6 it/1 fl/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. 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.
aJ