Mc Kinney, Robert ..c•• .Vnn J.Oft.G VGrAnIIRCnI yr ',camn
lk 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. .--,1�3-
5601 Warren T8iaix$ Glens Fa 11s
Dist. No. Countyor City
If city, give street address)
Name of deceased Robert-_.A.--'McKinney Veteran ye-9 vr7 I
(If veteran, give name of War)
Single,married,widowed,
Sex male- or divorced (write the word) divorced Date of Death 3/23 1976-_
Age 83 Yea Month dys Birthplace Tn of 'uue ens bury,_-_Iy-Y
Cause of Death -- i -<- , -=if.t. vA-cam
Certificate was signed-; -7490r___Michae1_.Mast.ri Brij M.D.
Address 100 z a-y_- -t_,_-Glens--r ells--,---NY 1280 ..
Place of Burial (or Removal) Tn.-_-of-.._:queens-bury.,-_NY
(If body is to be temporarily held, fill in space later)
Cemetery Pineview Date of Burial-_3/25 19_-76
(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 COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GRANT A PERMIT
to Carle to-n-- Amer-al lIaPae-, Inc. Hudson balls I --��'Y
(Name) (Address)
the Funeral -Director to hold temporarily and inter the body
(Un erta er or per n having charge of corpse) (Int emove, or otherwise disppoose of (state how))
Dated ---- wC.L° aZ-,}' 19 ,7 (Signed) Mce
This Permit is sufficient for the Removal (and Interment or Cremation) of a b y 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) (4A2-179)
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ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENT'S
OR CREMATIONS ARE MADE
Date of was 19/
(Interment or Cremation)
(Name of Cemetery, nstoriu+,�of",)
Section / . i Lot No. ve o.
(Sign y��✓ /mow, /
erson in Charge)
Ar9
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
UNDERTAKER 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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars 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 Deceased ®Hale Age(yrs.LLSi1,3
Robert A. McKinney ❑ Female
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
r1ens Falls Hospital , (lens Falls , NY 3/23/76 6,v4 ES 7IVE lip-Apr .7-An ti R 6
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Cemetery now interred Location (city, town or county) Is body to be transported by common carrier?
Pineview Cemetery Town of Oueensbury, NY ❑ Yes ap{No
State fully the final disposition to be made of body.
Bo'y to he i.nteree in Brown Cemetery, Town of Ft. Ann, New York
Name of place or cemetery for final disposition Date of final disposition
Brown Cemetery 4/22/76
Firm Na tee Reg. No. Address
Carleton riuneral Home, Inc. 00356 68 Main St. , Hudson Falls, N.y.
'Signature of Funeral Director or Undert6ker Reg. No. Date
C. Bruce Wetmore C Wit'G lC' �C:�� 111,/vir 05978 4/21/76
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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.