Conklin, Ruth «.� NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) 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. �j� 77
Z(.).(1-1P1,-,--1.1
Town, VillageReg;i re`�QDist. No.. 0/ County or City y
(If city, give street addrei
j� iii//l
Name of deceased letA—Zt Gi--)1 =' x- Veteran
(If ve eran, give name of War)
Single, marri , widowed,
5 :t or divorced (write the word) . .�- re.„ Date of Death .. .7-- `L c.19 .--7
Age 6?;...........Years .M nthsi ) Days Birthplace / - - •
Cause of Death
Certificate was signed b th. ..1. a M.D.
Address ...3.....4r1
Place of Burial or Removal)
(If bodyis to be porarilyheld 1 in space ter > /
Cemetry , C/ Date of Burial .C-_: ?6 19 •
(If body is to hes temporarily held, fi in space ater
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 r corded it in my Lo al Record wi the above stated Registered Number and on e basis thereof I/fH/JERE�BAY GRANT A
PERMIT G I C7 ��L�C�c-1 Icy
to • . .. . . /
Ma el' / / a ressS `
the �`� to hold temporarily and .. ' -� the body
(Under r or person having charge of co4se) (Inter, •ve, or otherwise dispose of (state how))
Dated -.2-r 19 (Signed)
" 'R r
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an" :'" ( 'ect to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit ''' No. 2) is re
FORM VS. 61. (ItI.V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 197 was �
(Interment or ram'— __
(Name of Cemetery,
Section Lot No. Grallo._L�
(Signe
Person in Charge)
Address
4 ,
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 UNDE;-
TAKER MUST SIGN ABOVE STATEMENT, write acro
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registr
of District in which cemetery is located. I
r #.
04,
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. Tbis 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•)
Ruth May ConklinFemale 76
Place of Death (indicate•-nhether city, village or town) Date of Leath Cause of Death
City of Glens Falls 2/24/76 Heart failure
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Rec. Vault Town of Queensbury 0 Yes
gi No
•
State fully the final disposition to be made of body.
Internment
name of place or cemetery for final disposition Date of final disposition
Griswold Cemetery, Town of Moreau, N.Y. 4/3/76
,Firm Name Reg. No. Address
:{Ogca.il Cx I1.14 .i.Ill.w 02883 quaker Rd. ,G.t.e21s Falls, N.Y. 12601
;Signature of 'un al G ctor or dert Reg. No. Date
i!G��� 04794 I/3 /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.