Waldron, Barney w
11 NEW YORK STATE DEPARTMENT OF HEALTH
v
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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, Vill14;.-p/ 76,77d Nt
Dist. No..-) '`-- 1 ountyA) or Cit
(If city, ' .e sireerffitddr
Name of deceased . Veteran
(If veteran, give name of War)
. . gle, married, widowed, (j) d .Sex or divorced(write the word) ,),A1;-24-A-)2-1-/ Date of Det1 :.1 "-:or' ( 19
Age nths • Day irthplace. ,
Cause of Death
Certificate was si ed
el
. M.D.
->
Address _,..
?A' -a
Place of BLA. oernpa s v raRrertl14...,_.fill..
:477iit4Vii-i) '141.46.(If body is t.. -
Cemetery ....rAq(.1.9---.1./..,i. 4.-a..,) Date of Burial ,7 —2-i— 19 76
(If body is to he temporarily held, fil in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same ,ppearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQU D BY LAW, I have accepted the same for registra-
tion, has recorded it in my Local Rec rd with the above stated Registered ber, and on the 's thereof I HEREBY GRANT A
PE I T .
to ). .,C.14.A<S.., •- ' c,--(
(Na ) (Address)
the to hold temporarily and Q---e ,- the body
(Unthtrt er or,rson h);:ing charge of corpse) ( , rem or otherwise dispose 19 (Signed) of (state how))
Dated —d ?6 .; ...
This Permit is sufficient for the Removal (and Interment or Cremation)of a body any pan of the 5 bject 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)
K ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
t 4 CREMATIONS ARE MADE
Date 4y74.411/' was C)--et a' 1974
(Interment or Cremation)
RZ., r--•-'C.- -j‘,
(Name of Cemeter}.r€rcmatonum, etc,.T-a "'
Section V '//Lot No. ve N6-
/
(Sign 1
(Person in Charge)
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above dat o
person is in charge, the FUNERAL DIRECTOR or U
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Regi
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER
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.
sr-
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 Deceased Male Age(yrs.)Barney H. :'caldron Female 85
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City of Glens Falls, N.Y. 2/21/76 Heart failure
Cemetery now interred Location(city,town or county) Is body to be transported by common carrier?
Pine View Rec. Vault Tn of queens bury, N.Y. 0 Yes ja No
State fully the final disposition to be made of body.Internment
hadte of place or cemetery for final disposition Date of final disposition
Waldron Family Cemetery, Tn of Luzerne N.Y. 5/12/76
,Firm Name Reg. No. Address
"RPran 2,- 7arrn-r, Inc. 0288 quaker ?d Glen.-' Falls_ " , Ys
;Signature of Funeral Director or dent .er Reg. No. ate
047;4 5/7/76
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
I. See Section 13.1 (formerly Chapter X111, 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.
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