La Foy, Laura NEW TVRK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
inr 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.
a 800 Town,Village �/
Dist. No. County 1)/(4� ) C Q M f�Y es-City -/ 1 ilt $ i E/4 _fjn(,,,
If city, give street address)
Name of deceased i•/4 OR.A E. L 4 JQ_V Veteran
(If veteran, give name of War)
Single,married,widowed, -.,
Sex _ �£/)l A k E or divorced (write the word) __/:_Pf.a.LL Date of Death A A• 15 ____ 19..A.
Age iiii ._ EA_fK Years Months Days Birthplace ii,Y. S..
Cause of Death AN v_X 1 A _
Certificate was signed by Ai D_1�/_1 V F C ti' M.D.
Address /§j/ L�c�/ fi R K /i E.j /9 ,n 5' i f R /1 nt, AI /
Place of oaf (er Removal) LY Li E#J S l J R , /ti• 7.
(If body is to be temporarily held, fill in spat later) i�/ 1 /
Cemetery r/1J __1l/£ __._ FCe/_rl/_ti1�' VA U 4..7 Date of Burial J 1v. /S7 19.
(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 Git'ANT A PERMIT A C/)
to J iJ k,l 1� ithl• /y l i/tl A NIA) 'i/C. 61A S ^� ��(..( S I. V
)) (Name) ) (Address) 3 /V
the 1• ` t 6 /e v4.A. / ✓i9 d to hold temporarily and re U yi ____ the body
(Unler is or person having charge of corps ) (Inter, re n e, or other os of (state how))
Dated ,.2(.-u--oc,% /SI 19 L. (Signed)
/ Local Registrar
This Pe it 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. (REV. 6/63) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
1114 CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
� /q
Date of was 19
(Interment or C )
(Name of Cemetery, CgematDTtum;—ems.)
f� �r i— //
U c z-
Section Lot No. G ve No.
(Signe r-v—
(Person in Charge)
Address P7
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 Dece ed r/� /� O?Hale Age(yrs.)
esL.L�_ t�F..�C--� •
® Female i�l`���^'.""' Z --
Place of Death (indicate•whether city,village or tow Date of Death Cause of Death
? t .r1 /j/..r 7l•-
Cemetery now interred '/� ®� Location(city,town or county) �,/ Is body to be transported by common carrier?
�AMl�a . 1/4.1. .4: _ 43i1_e..1 Z Q Yes pik No
State fully the final disposition to be made of body.
Name f place or ceme ry fo f al dispositlo Date of, fin 1 disposition
>.f.u•r.g/14".r s..4.• 02,�7 lr
Fir Name R g. No. Address
` • lK •, .
;Signature of e Director or Undert. er • Ret. No. Date
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.