Lydecker, John NEW YORK STATE DEPARTMENT OF HEALTH
t_ i_, - OFFICIAL BURIAL (OR REMOVAL) PERMIT
air 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. ID
_ Town, Village Registered No.
Dist. No. 0 \ County -�C�` ' or City ���`t--, .`i co c'")
(If city,give street address)
Name of deceasedti"(>. . �4S\ Veteran ` �JC)
(If veteran, give name of War)
Single, married, widowed,
Sex � Q or divorced (write the word) .O.. .0 Date of Death rc\.(� .. - ....C.2..19 1 Ca...
Age D' I Years Months Days Birthplace .
Cause of Death C...Z51.C..,. .,��( -
s ....),, .. ..�;YN..�.. M.D
Certificate was signed by �,.'.., ,..�>>
Address 0 ),- :.-., XJ> Jac"^ .:> C—, -'V
Place of Burial (or Removal) .. `\''N. a C) i;,.;�,..�
(If body is to be temporarily held, II pace to )
Cemetery 41. 2, . ..i,J--; C.:.: mac.:: Date of Burial �t1 G 19 -1
(If body is to he 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 registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
P E RMtt) ,-•-
\'�` cr,�,, a.. ��,. .. • �k .�. ...(� t as 1�-_/'
( ame)
the .. 1'\ ...1..c--k- to hold temporarily and c;Lr c the body
(Under. er or per on hay , charge of corpse) Inter, remove, or otherwise dispose of (state how))
Dated ........�., `�. 19 �(o (Signed) \� `(Y� c' �
\ Local Regigtrilr-
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 regulation Is), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FOd1tm VS. 61. t Rb:V. 6/63) (A2-248)
I ENDORSEMENT OF SEXTON OR PERSON IN C. ARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of��'Z1121-44 as /"""2
(Interment or Cremation)
(1_41,-1-2LG'
(Name of Cemetery,-(Crematorium, etc.)
Section r 'L '-Lot No. Grave No. -
(Signed)
(Person in Charge)
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.
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 tiMale Age(yrs.)
John Re Lydecker 0 Female 57
Place of Death (indicate •shether city, village or town) Date of Death Cause of Death
City of Glens Falls, N.Y. 3/17/76 Heart failure
Cemetery now interred Location (city,town or county) 1Is body to be transported by common carrier?
Pine View Rec. Vault Tn of Queensbury, N.Y. 0 Yes (No
State fully the final disposition to be made of body.
Internment
Name of place or cemetery for final disposition Date of final disposition
North Argyle Cemetery, Argyle N.Y. 4/10f76
Firm Name Reg. No. Address
: an '' n11-ss'9 Inc, 02883 4ua_ker t?r e ,G_j_car.. Falls, N. t e __
4i;19
;Signature of Yu •iry'tor or ertR Reg. No. Date
i -- 04794 4/7/76
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.
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