Duell, Leah NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
«` 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. No. ,c ``) County �`'`'Y`� or City w
(If city, the street address)
Name of deceased ,-e-it,.. &-'' - ' Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) Date of Death IC - ( 19 .. )-7.
Age Years .Months Days Birthplace
Cause of Death
Certificate was signed by �"' M.D.
Address
Place of Burial (or Removal
(If body is to be temporarily held, (ill in space later)
Cemetery Date of Burial 19
(If body is to he 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 registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMITto "i/I'' ./..C; Pr- - p y
(N e) ( (Address)
the m to hold temporarily and ,�-✓ ' „„ the body
(Undertaker or person hying charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated 1/-- tr.. c'1 19 1 (Signed) P - --C—
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) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of z ' ; 3t;.err-1\ was iv 19 77
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in Charge)
2
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER 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 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.
1NG.w 1v1‘1% JIMIG YGrnK1memi Vr fCMLIP7
r l OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. ,, ,s
Town, Village ,5�
Dist. No. ��'0/ County J or City v o
If city, give street address)
Name of deceased C.7 `- ,(_ eran
11 (If veteran, give name of War)
Single, married,widowed,
Sex ____t a ._ or divorced (write the word) M Date of Death /—/c 19 77
s--
Age 74 Years /- a.4 Months Days Birthplace ."
Cause of Death _. . ___
Certificate was signed by spv[_.__.. ac.../ M.D.
Address � �
Place of Burial (or Removal , �s“ . 4z,...Q......„.,,,,,,,c(If body is to be temporar' held, 1 in space later)Cemetery
�-�x�_�,zc�� ��� Date of Burial ` /� 19 77
(If body is to be temporarily held, fill in space later) t
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 GR A PERM.
to -e-c---n -->0 /�- .. y'e1---.`.° d`„ .
(Name) (Addtess)
the 2 (.a..r k.- to hold temporarily and ,6-- - the body
(Unlertaker or person having charge of corpse) (Inter,(remove, otherwise d'ipose of (state how))
Dated /7 19...7? (Signed) 'ii�f,.t7 ›'di
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)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of C7 nz-t was /c19 77
(Interment or
(Name of Cemetery, C�aniataZillan,-ett.)
Section Lot No. ave No.
(Signe
(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.
I hereby request permission to disinter the dead body of:
Name of Deceased Male Age(yrs.)
Leah M_ D1]A1 T ® Female 7 .
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
Glens Falls New York !:/1/02 Cebeb kl Emboli soiu
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Cem Vault Twn Q11AAnelbury' NY
D Yes im No
State fully the final disposition to be made of body.
to be intered
Name of place or cemetery rfor final disposition Date of final disposition
West Glens ails em Twn nE+Pneljap. NY 1 7/77
Firm Narre Reg. No. Address
Potte' Funeral Servil 019�41136 Warren St Glens Fails NY
;Signatur of 'unerat Director o nderq'gk Reg. No. Date - --' --
1\ I% oh h A' 1/17/77
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.