Pattee, Mary ..` NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ra- 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.
��j Town, Village Registered No.
Dist. No. ..56 v ) County (it/ ..or City '
�] (If city, give street address)
Name of deceased XL, ' ai �n� eteran
(If veteran, give name of War)
Single, married, widowed,
Sex ‘ or divorced(write the word) ( .4-4-e- Q,!.h.41 Date of Death / 2- 19 7)
Age -2 Years .Months D s — �l Birthplace..... ...........
Cause of Death :.. Ll
Certificate was signed by ,... ,
� , M.D.
Address c .1� -� ...�'
Place of Burial (or Removal
(If body is to be orartly"'he d, fa:Me s ace �7
Cemetery ,_ �,�/ Lr��.�4 -/ Date ofil
l / z 197�
(If body is to be4emporarity held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same a,ppearing to be COMPLETE, CORRECT, AND SATISF RY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hay recorded it in my Local Record with the above to a Registered Number.and on a basis thereof
�II HEREBY GRANT A
to tiOLLt-7 47't, --1-C- ,
(Na e) (Aaress)
the to hold temporarily and the body
( nde aker or, ers n ay..: c arse of corpse-)— (In remove, or oche tse d4 pose of (state how))
Dated .. r 19 7) (Signed)
L'tfcr:19e( sir
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part of t..c 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 was 19 `�
(Interment or
(Name of Cemetery, Gr+atorium.�w,-)
Section Lot No. e 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 TNREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
violating the law relative to the return of permits are liable
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
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. Tbis is a permanent record. When data cannot be obtained, write "UNKNOWN"
in applicable spaces.
hereby request permission to disinter the dead body of:
Name of Deceased Male Age(yrs.)
Mary H. Pattee Female 74
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
Glens Falls, N.Y. 1/25/75 Heart attack
Cemetery now interred Location (city, town or county) Is body to be transported by common carrier?
Pine View Rec. Vault Tn of Queensbury,NY 0 Yes lallo
•
State fully the final disposition to be made of body.
Internment - Union Cemetery, Town of Fort Edward, N.Y.
Name of place or cemetery for final disposition Date of final disposition
Union Cemetery, Town of Fort Edward 4/23/75
Firm Name Reg. No. Address
Regan Denny, nc. 02883 Quaker Rd. ,Glens Falls, N.Y.
(9lgnatw'c o I' nera irect.. • Vndert r .._,.
or'
04794 4/22/75 .
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.