Frazier, Albert 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 a Male Age(yrs.)
Albert S. Frazier 0 Female 96
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City of Glens Falls 2/16/76 Brohoho Pneumionoa ,
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Cern Vault Twn Queensbury NY 0 Yes 9 No
State fully the final disposition to be made of body.
To be Intered
+Nettle of place or cemetery for final disposition Date of final disposition
Bethlehem Cemetery ,Elesmere, NY F3a tma3xtta. 44176
Firm Name Reg. No. Address
Potte Funere ie, 01974 136 Warren St Glens Falls N.Y.
7
;Stgrteft�s f Funeral Dire or- d — ------ - Reg. No. - Date- --
t _ - ol111-62 1l/ /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. Tbis form should be filed and carefully preserved in your office.