Maxim, Ina y NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
«, This Permit can be signed only by the Local Registrar (Deputy or subregislrar) 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. / v
�,l
Town, Vi e egis re o. 'S
Dist. No..Z.. G ( County J,.,•/�/ or City ....... ... ;(,)../
�
(If city dre've-stfee^ ss)Name of eased . .. ..... . 927 27rCt---X-.44,2,u-. Veteran v``
Single, married, widowed, �q
(If veteran, give name of War)
Se ,..• or divorced(write the word ✓���.; t vt r 1 Date of Dea�' —' 19 .26
Age. ..,... s.... .Moths Days Birthplace <• ••. .-.....
Ca o/f Death 1 � .. . a'i ! . 4__/
/
Certificate was signed .y...:`r . . ' M.D.
Address �: .�. _ � ..,.... ..
Place of Bun (o Re ova A. . '.. .
(If body is to e t poraril id.. i , in -•. e l r)..... 1111
Cemetery .......J,,/.Y_►iI;,.. .Xi2 ............... Date of Burial 3'c 192( .
(If body is to-e temporarily held, fill in •. e 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 i Local Record th the above stated Regist/ . Number, on th bas{ ereof I HEREBY GRANT A
Q
PERAf
/ - ...„474_,, lel,
to the Name ( 1 ' c dar sr v
VVV// to hold temporarily .,.- . the body
n ertaker persop ving charge of cc ps ) (In I • move f oth ' ise "spose of (state how))
Dated ./ 7 19 .`f��j� (Signed)
ocal Regis
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. (RM:V. 6/63) (A2-248)
oir
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
� 2 j�
Date of was 19
(Interment or
(Name of Cemetery, r._. ..1
Section ' ' 'Lot No. Grave No.
Si ed) � ".1.
(Person in Charge)
Address /�-�,A /7/
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 U ,' R-
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 Regr
of District in which cemetery is located.
4
SEXTONS, FUNERAL DIRECTORS and UNDERTAK
violating the law relative to the return of permits are liable
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.
3 as
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.)
Ina
M. Max m Female 70
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City o1 Glens F l. l: , v• Y. 3/17/76 Heart failure
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pane ViewViewr ram,�, 0 Yes _;4] No
Rec. Vault Ln o� ueei,; r;�, v Y �l.,_,
State fully the finaly� disposition to be made of body.
-i
11ie r Sii.;A'n1.
Jay
Bartle of place or cemetery for final disposition Date of final disposition
Old ay Hill Celue uerY, Jay, Maine ?! 26/`i >
Firm Nate Reg. No. Address
'.t',�,: '4 '1 ,. i+ Inc {��t> .F, .J17r`3-. 1=?T"'_ r=a�fry '.1_ �i��11. ti i.. l+t s
;Signatutr�of Funeral . • or or,i*dertnice Reg. No. Date
• 04794 . «
•
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.