Thomson, Minnie , • NEW YORK STATE DEPARTMENT OF HEALTH
—` OFFICIAL BURIAL (OR REMOVAL) PERMIT
a- This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vi!rage, 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. /a
4..2.0...,
Town, Village iegist d�/N�o.Dist. No..�J76t/ County ... .. or City lA
(If city, give street addres
Name of deceased ��� Veteran
• (If veteran, give name of War)
Single, married, widowed,
Se „,... �(�u or divorced (write the word) �� Date of Death-y, � 74. 19 ' ......
Age L. Ye Months .... Days Birthplace / `.-4,�7
Cause of Death •
Certificate was signe by.... -Y-� • M.D.
Address ;7 ........g.., /U ZW X-t 21t
Place of Burial (or Removal) r
(If body is to be porarily h9 d, {ill in p later
i )1-7
Cemetery lL. Cc�..... Ll Date of Burial , vG�.au�_• 7 197,E
(If body is to be 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 COMPLET , CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have re ded it in my Loca Record with the above stated Registered Nu r, and o he basis thereof I HEREBY GRANT A
PERMIT
7 . N,.. )-i,_.e. ..?,?--c--Je Nj-'e Z
to ,. ‘C. Name) (Ad ss) Zebody
the to hold temporarily and
(Under k r r person awing charge of con se) (Inter, remove, or otherwise dispose of (state how))
Dated .7 19 ... ,- (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a part r ,Ael oIc the tate (su 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. (ItI V. 6/63) (A2-248)
• s ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date 2G.ti) was )7/i-A-1 % 19
(Interment or Erema;io .)----.--
i
(Name of Cemetery, num, erc.)
4#4
Section Lot No. e No.
(Signed Z ZC
(Person in Charge)
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.
NEW YORK STATE DEPARTMENT OF HEALTH
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,
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.
��-{{..c� Town, Village Registered No.
Dist. No. .62.6...2 County LJ.C.l i ' C,•• or City (`,..:.A-,-, .. '.....(s:l_a, $ ci!-i":i
(Tf city, give street address)
Name of deceased ..12.1..i.ri.n...,:...r.. 1r}_.... ..)1. .r.,.S.e-s Veteran
(If veteran, give name of War)
Single, m-rried widowed,
Sex FK-' v. �A— ., or divo .-d ( ite the word) Date of Death 3 -7 - 19 .7(..
Age ' 2 Years t onth's Days Birthplace
Cause of Death .. - C:.afl.:h...:.....
Certificate was signed by M.D.
Address `
Place of Burial (or Removal) r-;,t) ..? : c •-.J
(If body is to be temporayl y held, i in space later)
Cemetery //.k T rr-e,e 0.^%` Date of Burial 2-- 3.,.0 19 7 C
(If body is to beltemporarily held, ll-in space later)
The CERTIFICATE OF DEAT containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COUPLE E_, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it,.Tn my)Loc1l Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT ! Q/�I r,
to ti '1 7..C:. NS C)...0 o,k er a. L P-i t Fa L-(d , -1717
,` k_ (Name) (Address) /�
the (-1^d °rYam` k Q.' .;. to hold temporarily and iZ c.n,4 a ._ the body
(Undertaker or person havthg charge of corpse) ,_(Inter, remove, or otherwise� dispose of (state how))
Dated ......a -...," c' __ i 19 7 a (Signed) 1�G ....�,1.o--�� t.-.1. t k4e:-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.
FOItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
i OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o ( ' ' i, was `4-' 197'
(Interment or Ca sarrdr
(Name of Cemetery, C i^a4^-i••m
Section / Lot No. Grave No.
(Signed) i ��Z
(Person in Charge)
i71
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.
a 'I
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 DeceasedA _ / Mal Age(yrs.)Aim/,., A ��0/1so"o emale s/8
Place of Death(indicate whether city, village or town) Date of Death Cause of Death - -
c1 £ eA'J 1 1L_f 3/4/7.-‘ CZt.2/r n
Cem tery ow�int ed - {,o/motion(city,town or county) 6.447
Is body to be tra ported by comet arrier?
Y /l` /�/�lJ G' C.1 E�('/t-''S , Yeaitf %.(
o fully the final disposition to be made of body.
i
Kam of pace or a etery for final disposition Date of final isposition
/ 1`' ,�#1r� <3�3o/7 4. ,
Firm Name Reg.No. Address
—Rep,'> ti ;� .zl Ste. ;(��� a ��s /� �' 6 �,, .16..
.Sl at% a if 'uneral tractor Unde ker Reg. Igo. Date
/ O v7q' 3�3/7_4 .
._,2
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.
y