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Rogerson, John 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, 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. Registered No. TagliTa Dist. No. 5501 ,_,..„county Ulster ofyirtllARE Kingston _ (If city, give street address) Name of decease' "-::,/ri„%�'.L..;t F, X.0-9 i i" (4 ',/ Veteran / .) (If veteran, give name of War) Single, married, widowed, 1 a Sex , / or divorced (write the word) 604.(".Ci.i:.td( Date of Death ( ' , 19/..�� Age d Years Monts Days Birthplace =?. ,'kt� i,� Lref Cause of Death 6C k... .. � Y t ..,:k.,JJ . .. t:.i..e...l'.is.:e ,,,�� Certificate was signed by ,4-ii--'. - . £, f,,, / -I r ti f..�'l(.,... M.D. Address . 4'6Q aL= `� '' , aU...l.:'.. �.g.1.-: ( .,�� ('I 7'......../..���/..�.�, Place of Burial (or Removal) .... . (If body is to be-r,mporarily.,he d, t in-space later) / � / ?�` Cemetery �.. 4.'14— !I Date of Burial 6 / ) 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, aft r careful examination, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra- tion, ha e r or ed it in rryp Local Record with the above stated Registered Number and on the basis hereof I EREBY GRANT A PERMIT �` r f // _.a n:h. ( , , �,f /• (Name) (Address) the L tt.L:! -V-PA W '1r— • to hold temporarily - .. the body (Undertaker,pr erso having charge of corpse) der remov= - h e ,p ifjf (state how)) Dated E:. •(, , 19. (Signed) / / ' /! , III;" •... Lo rj„, egis ar This Permit is sufficient for the Removal (and Interment or Cremation) if a body to any part of t..c State (sub'e t to local cemetery or other regulations), unless removal is by common carrier, in which case a ransit Permit(VS No. 62) is require. 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 4:41-74/ L 19 ,77. (Interment or (Name of Cemetery:`= --�.;, Section V GL iot No. L?� � ( • ' (Person in Charge) Addr eR 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. X 64 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. • V NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT rar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town, Vilthge, 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. n' Town, Village Registered No. Dist. No. )'J ' County 11' ' ` . or City '��-"'-�``_" f If city, give stre#r ddress) Name of deceased �.�i,'v\ --r-re7—c.-'—._ Veteran (If veteran, give name of War) Sex 1� Single, married, widowed, i ,. or divorced (write the word) Date of Death ! 19 Age Years x .Months Days Birthplace Cause of Death , 44-6,- A.w•-�., Certificate was signed by „,, M.D. Address - -' Place of Burial (or Removal " y — , i" (If body is to be temporarily h 7iii i ace l tei Cemetery -f - - Date of Burial ' )- L 19 '),F (If body is to he temporarily h fill in space later) The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the same akppearing 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 n to J �" ,;:.� /c: ',-- a Z 11,c-r- _-, I'i ,i.C:,d t.-t =J (Name) (Address) .... the ', to hold temporarily and the body ,t ndertaker'or person having charge of corps.) (Inter, remove, or otherwise dispose of (state how)) D ted Vs-IA-4-A- ) L'' 19 , S (Signed) ,,,,— ' G 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 corrier, in which case a Transit Permit (VS No. 62) is required. FOItM VS. 61. (REV. 6/63) (A2-248) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR 4` CREMATIONS ARE MADE Date of41;; 'e was " '.9 (Interment or Grea ) _,,/"CCels (Name of Cemetery, ritmti . etc_„)- Section Lot No. Grave No. (Signed) _ ,A--L- (e, xr---),-,....L./( ), (Person in Charge) ,4-97 / _�- Address 't��d�� 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. `,, 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 ce/ssed ! a1e Age(yrs•)_ .) 0II 11 r � �M It (.�L•,T 4 L 112l� 0 Female ceePlace f Death (indicate .vhethe city, village or town) Date of Leath Cause' of Death —�. J 1 t t/l ` S L ''), !V �`r //41 7( 1.t b�l C I C V 7C /.'IC tc.,-.;fret!'it�;"- --- C metery tow interred f 1,oc tion(city,town or county) Is body to b/ransported by n carrier? �' 0 Yes commNo I-1 lie, Vat,Cue I/'4'-''-" I r 7.vt, L.',„,cr. i b,..4......./ A x State fully the final disposition to be made of body. 1-I1 r-,..r,C,.1 Name of place or cemetery for fine disposition Date of fi 1 dlspos tion �`C'4 nth �--� -� C 7S' S c 1 tt �, ;Y r.-;�,. t 0` `Firm Name� r Reg. No. t' ddress ,/ f'' /� �i N 1), 1,l e jr�' 't�!i,.r I yi/I ft o1 2Y S- I v "4 Y�AZ+d��J/ (!�/t h �! (� //S �/ ;sign. of Funeral Dir or er Uptite -- Reg. No. _ Date 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 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.