Traver, Olive ,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rir 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.
Town, Village
Registered No. �"`���
Dist. No. ....,'-.A I County d'`t'—^--- or City Q°'^- -
(If city, giv street address)
Name of deceased tr4-4.-s'e_ f A-m..A,' Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex �f or divorced (write the word) Date of Death a -.1-3 19 , 1-.-.
Age -7 �' Years .Months Days Birthplace
Cause of Death C. ' '
Certificate was signed by M.D.
Address �-
Place of Burial (or Removal) .,, .
(If body is to be temporarily held, (111in 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
PERMIT
to , • 744 14.�. c` '14-ar,‘y N.. fr 1y ,•�..;*,4-fit
)14::-.--Ltk,. ame) (Address)
the to hold temporarily and the body
(Undertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated 1"'',�.. . (^\ 19 "1 7 (Signed) Q <_-9--_._.___
Local This Permit is sufficient for the Removal (and Interment or Cremation)of a bodyto anypart of the Registrart
, (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'� '``t'‘ was 19 22
(Interment or Cremation)
(")-<n.t
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
"4-7
(Signed),
(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 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.
...-
A. NEW YORK STATE DEPARTMENT OF HEALTH
,..
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far" This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Viltage, 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.
.
Registered No /3
Town, Village ,.,
Dist. No. County County Lt--) ct,, , f. ,,- or City 0-14../../..m..0,,\‘........ NM Li. Ls .4., ,
(If city, give street address)
Name of deceased C.A,...;..Q...:_ c".. ‘-.. r.A...a.,' c t- Veteran 0, ::.
(If veteran, give name of War)
Single, married, widowed,
Sex .1- €---. se-,,,•,—\,.41,... or divorced (write the word) l'ick, ,-,.,.,1 Date of Death ,..2-...2- 3. - 19 2 2
Age 'D (":" Years .Months Days Birthplace 4.,. r-)/
Cause of Death .(.-%.C.....k..c,..,..,,,..e.. 4 ce.?,c ilabr("g . - '-i Lit._ yr,--44,:".... -1
Certificate was signed by „....1 . ,..,,.a\---.---,Q. <...-..- ,-4---...--e - M.D. •
Address (;--- Po-N R IA. (2,,IF:1-Y . Afy
... , •
Place of Burial (or Removal) 7r-0,-,, — r.,..... (2)-', ,-,
(If body is to 11)e temporarily held,..fill in space later)
Cemetery ' 1.:.1.e_0..., e' ''',3 0.-' e .f••. N e A Date of Burial .:2-..2 5- 19 77
(If body is to 4be temporarily held, fill in space late?)
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
PERMIT
to 1 J
-J 4 i-te i- , 74 e, ,,..., ,,
(.,s., 4,7 6"--)ct , i e'\ r 1 C:.) e,..4 r a(l J., --)7
(Name) (Ahresi) —
the U. ,,, a'-e -4"' k e•-• to hold temporarily and ,--- --h.ct f- the body
(Undertaker or person having charge of corpse) 4.1kter, remove, or otherwise dispos f, tote how))
Dated -2 -z=2. V - 19 7 "2 (Signed) ...L -- - ",z,- ',K-.--..---iTh ...,
4-.
Local Regis
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 --/G was U aS 19 ,7
(Interment or Cremation)
(Name of Cemetery,
Section Lot No. Grave No.
(Signed)
(person in Charge)
Address f{�'/`t1 � ielErg Imo"
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.
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 ofDeceased Male Age(yrs.)
nitre F T'Y►Wo" ® Female 70
Place of Death (indicate whether city, villaKe or town) Date of Death Cause of Death
Town of Queensbury NY 2/23/77 Carcinoma off Breast
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Com Vault Twn Queensbury, NY 0 Yes I No
State fully the final disposition to be made of body.
To be intered
t:ache of place or cemetery for final disposition Date of final disposition
West Glens Falls yen Twn Queensbury NY 3117/77
Firm Name peg. No. Address
Potte Funeral Se»i e o197I� 136 Warren St Glens Fails NY
Signaturgr or Funeral Direct or nd Reg. No. Date
,- r
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.