Stewart, Bertha •
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.)
Bertha j i. Stewart emale 8b
Place of Death (indicate.•,hether city, village or town) Date of Death Cause of Death
Town of Queensbury, N.Y. 12/29/75 Heart failure
Cemetery now interred Location(city,town or county) Is body to be transported by common carrier?
Pine View Rev. Vault Town of queensbury, N.Y. 0 yes
Q No a
State fully the final disposition to be made of body.
Internment
r:adie of place or cemetery for final disposition Date of final disposition
Mt. Hope Cemetery, Ticonderoga, N. Y. 5/29/76
Firm Nacre Reg. No. Address
Regan &Denny, moil 02883 Quaker Pd. ,Glens,Glens Falls, N.Y. 12801
;Slgn`elvwe of Funefic•trect• or V ert. Reg. No. Date
• 04794 5/28/76
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.