Kelley, Thomas nCr1r iVKR JIAIC Ut AKIMCPII Vr ritALiri
.t OFFICIAL BURIAL (OR REMOVAL) PERMIT
ier 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. 2
Registered No.
TM=Village
Dist. No. 5726 County We shington 1XIDCAW Hud.aon Falls_
If city, give street address)
Name of deceased Thory,,s William Kelley Veteran no
(If veteran,give name of War)
Single, married,widowed,
Sex male or divorced (write the word) single Date of Death _.._mar._.23---------- 19__76
Age 20 Years Months Days Birthplace Glens Ff711..LS ,. Ny
Cause of Death my u c ii\ 1 Y•) I vAL . A f L L) ✓, E
Certificate was signed by Dr Robert Homer M.D.
Address 100 John St, , Hudson Falls, NY 12_83_,I
Place of Burial (or Removal) Tn of ueensbury
(If body is to be temporarily held, fill in space later)
Cemetery Pine view Date of Burial _312 5/ 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 Carleton Funeral Home, Inc Hudson Fa11s_,_.NY
(Name) (Address)
the 1e : ._.Dire_c_tor to hold temporarily a . renoval the body
(Unlertaker or person having charge of corpse) I er, remove, or o r ispose of (state how))
Dated Maxch__24., 1976 (Signed) __ e.--v-uY �� "--f------
Local Registrar
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. (REV. 6/63) (4A2-179)
f ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
a OR CREMATIONS ARE MADE
Date o ���E��� cwas ()* (4.),,"19 ��
(Interment or Cremation)
(Name of Cemetery, matorium, etc.)
7
Section � L�-�'� Lot No. Grweo.
, _
4
(Signed),
a _ , V
(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
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.
hereby request permission to disinter the dead body of:
Name of Deceased Coale Age(yrsl
Thr?'nas '1. Kelley ❑ Female
Place of Death (indicate .whether city, village or town) Date of Death Cause of Death
2 Oak t. , Hlxrlson Val. l w, NY 3/23/76 / iyac"viAL T-AIt UR.E
Cemetery now interred Location (city, town or county) Is hody to be transported by common carrier?
P'.nevtew Cemetery Town of Queensh1_lry ❑ Yes ni No
State fully the final disposition to he made of body.
To be intered
tram of plat r cemeter for final disposition Date f f'n 1 disposition
Foss reet Cemetery, own of Kingsbury, NY 4/26�76
Firm 13'atee Reg. No. Address
Carleton Funeral "ore, Inc. 00356 68 Main St. , Hudson Falls , NY
',Signature of Euneral Director or Undertaker Reg. No. Date
C (i[J •'; 'Pruce Wetmore G 05978 4/21/76
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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