Aubrey, Joyce NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
car 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// Town, Village4,6 Regis ered No. ..../2--6 '
Dist. No. ��o/ County U( Cam/ or City e
�yy (If city, give street addre s)
Name of deceasedLA /�/ c Veteran �—
(If veteran, give name of War)
Single, married, wido d,
Se 2T�7C1.r • or divorced (write the wor r Date of Death G�C9 1976
Age.....�... — Year Month Days Birthplace kvy -
Cause of Death
Certificate was signed by �• ,�� M.D.
Address Ct L // � �Z
Place of Burial Remov ,!. „r.(,.... G.�,.
(If body is to ber4porarily hd,•tll)in spac ater) / 2ul,T
Cemetery �(�a.e. CJ G�c Date of Burial ,.., / - 197'.
(If body is to be temporarily he d, fl tll to space ater)
The CERTIFICATE OF DEATH containing the above state particulars, having been presented to me, after careful examination,the
same appea ng to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have corded it in my Loc l ecord with the above stated Registered Numb_ , and on th basis ereof I HEREBY GRANT A
PERMIT �� iC/�'r 4.-- ---) .C?... �t/LK._- fto ame) Address) /
the �� to hold temporarily and Ii- ell'-a- the body
(Uncle er or per on having charge of corpse) ( y re ove, or otherwise dispose of (state how))
Dated ..... z....7s( 19 ..7.6 (Signed)
o
This Permit is sufficient for the Removal (and Interment or Cremation)of a body ny pa t of tbe3taksubject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
h'OItM VS. 61. (Rh:V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 11114,4 s )�--,-"-V 19,1n
(Interment or Cr iaticu)___
s
(Name of Cemetery, Gt i -tr.rir-e*r)
Section Y Lot No. rave No.
(Si
(Person in Charge)
Address "2i f
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date.
person is in charge, the FUNERAL DIRECTOR or UN
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Regis
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.
FormLS-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 •f Dece sed 2)7
Male Age(Yrs.)
ER Female
Place of :- �ndi to•whether city, vi,la1 ee�or t Date f L' aih 'Cause of Death
dril
•e T ry n•w 'nterred Lc, ion (city,town or county) Is body to be transported by,y1co.�mmon carrier?
�J I ht-W7 Q Yes f No
state fully the final disposition to be made of///body.
of place or cemetery for fin dlsposlt n Daof final disposition
n--
/s/ /9 7d
Firm Me Reg. No. Address
- - tore 1' ra-1 director or amnia r - - _ - -
A c�JY(_ cef2r�— 0S;c1r �a /
•
• INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter XII1, 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.
z