Van Dusen, Blanch _.y
: k � 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,
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 Re stered No. � /
Dist. No. .5(a..5 2 County � ms Kee or City R. `). , . K�!
,+1,
�^-� (If city, give street address)
Name of deceased {J L a,..4.,.. V42..4-7 LI....LL-Sr"- Veteran .1Y U
(If veteran, give name of War)
Single, married, widowed,
Sex r or divorced (write the word) 5: ri 9.4..:e. Date of Death ...L.-1.7- 19 2....�....
Age 2.5" Years Months Days Birthplace.......(..1.,...r.
Cause of Death 0....,.C..r..,....rta.., ,e) c.c.L..s...:nn-
Certificate was signed by +^- . fl) c Kcc ✓�l,1), M.D.
Address ✓. ...9 Na1 &i.'.. S {- SO Cjc.l...p.s.J /"za.4k.:S1 Ali
Place of Burial (or Removal)) ,.e.. ..a.a. V.:,7
(If body is to Fie temporarily held, sill ins ace later)
Cemetery I-'4 n C, a a..s,.L i Date of Burial /—,gib — 19)5
(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
PERMIT ) /n� 1,
to G�.Y.w o f S.......P....:-t7.r :.. ..Co.....�1.A ry P ti Sl,, C0 44'-s..� 4 4..h)....,T
( (Name) (Address)...
the �r k i',-* K..9 r to hold temporarily Lid i--A-. (, r...4t.i,,,) the body
(Undertaker or person having charge of corpse) (Inter, remove, or oche y'se dis ose of s ate how))
Dated /— 19 .2..5— (Signed)
Local Reg' ar /
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 Was 19
(Interment or,Cre Lion)---
(Name of Cemetery, Crematori.uml. etc.)
Section rLot No. Gr6ve No.
(Sign ) /42' (
(Person to Charge)
Address 12 'ij / - i�--
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.
,, - _
-+- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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.
i Town, Village Registered No.
Dist. No..�� County fiv'cr--"--`'--- or City
(If city, g et'addres
Name of deceased Oft-0—'` G Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) Date of Death ( ( 7 19 li-
Age -) If Years Months Days Birthplace
Cause of Death C V F#-
Certificate was signed by ^ M.D.
Address
Place of Burial (or Removal) .. . .. . .., i^
(If body is to be temp rarity held,-fin in spac )
Cemetery ' •-- -...r Date of Burial `r'.3 19 -?3--
(If body is to he temporarily held, fill i ace 1
The CERTIFICATE OF D TH tai ' the above stated particulars, having been presented to me, after careful examination, the
same Appearing to be CO E . RRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in L al Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT fit!
to 0 1.�• --f ./.42-,—`t ,.... l 3 c- 9'1! - ..I-.,A-,. ", I/
(Name) (Aa resd s) ' f'"
the to hold temporarily and ,.,t,n"tv the body
or pp having charge of corps (Inter, remove, or otherwise dispose of (state how))
Dat c 3 19 3 (Signed) i,9-""'`A --�.�..,,
G C-ts .
V 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
i
OF PREMISES ON WHICH INTERMENTS OR
i CREMATIONS ARE MADE
Date of wame rr :/47. ''' 9�
(Interment or
2Z /' ?1. —..—�/
(Name of Cemetery, Cae.m aae• ca
Section Lot No. Grave No.
�Y1 C
(Signed
( .4-117:1-74--41)
(Person in Charge)
r` /�----e J T
Address
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 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.
l hereby request permission to disinter the dead body of:
Nome of Deceased Male Age(yrs.
Blanch Tl'tanntutti n Female ?*/sp
Place of Death (indicate whether city, village or.to.vn) Date of Death Cause of Death
Town of 9ueeneb , N Y, 1/17/75 CVA .
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
?''Dire ViA! Ce�r Vffiii1$ T t u;Ye ❑ Yes No
�n �'I+Be�isb 1t'f�
State fully the final disposition to be made of body.
to be interact
Name of place or cemetery for final disposition - Date of final disposition
` Mt. Herman Cem.Town Of Oue nsburyw .Y. April 3. 1975
Firm Name peg. No. Address
Pot'b r F me 1 rT ,e 019.7 . Ir6i-Waxsrei_ St Glens Polls, N.Y, 12Rfl1
e o l'unera it for r .r .,ker Reg. No. Date
g f
7' r 014463 April 2, 1975
•
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.