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Norton, Sarah ir-' ' Form VS-b7 (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: )4o we of ceased /,y l � Male Age(yrs.) ��� to Y C CI ( M be '11 Female ,Place of Death (indicate .whether 'ty, illage or town) Date of Death Cause of Death f Cect!yery now ipterred i l,oc 'on (city,town or county) Is body to be transported by common carrier? I JJI Il C now, 1 e (.'e"'» I�6:fi -1 j v ii ��)•-a € '' l -/ /�/,"- i/y• ❑ Yes ja No State fullythe final disposition to be made of body. • 1 p I e I hlit'"rv'4 (Caws of place or cemetery for final '�disposition -, f /• Date pfin,I isposition r/Y(t✓► dri S C'wtc �',/ ) 4ueG+.S1�r7 �I` / it fI /'�'o Fir a / Reg. Mo.) Ad/dress` -�•' /� IVYil //)-fai S! netur t funeral Dire or o Uncle 2 � 1 g �,.�-- -- Reg. No. Date - INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER: 1. See Section I3.1 (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 Officjal 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. F NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMITlk III 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. ! 2 �, ��Q Town, VillageDist. No. / unty tk.) /� or City 7ot:A If city, give staddress) ' Name of deceased .. --._O it %.-+`i �� ' c _. Veteran (If veteran, 've name of War) Single, married,widowed, /, 9 Se or divorced (write the word) wL 4N-*� . Date of ath X 19./7 ' Age 9f Years _ _ Months __. Da Birthplace =_ Cause of Death G�4 cL�_ �(/c i.A,L Certificate was signed by ... . . . . . ... . . M.D. Address Q, d '. Qi>« C ct Place of Buria (or Removal) L - , (If body is to beiPporarily hey , yill in spa a ) ---- ; .Q, 4-� E��L� 17 /� r� Cemetery _ Date of Burial c� 19.._� (If body is to .: 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 regist ion, have recorde it in my Local R rd with the above stated Registered Number, d on the asis they of H RE- BY G A MIT /� / ( W�e 11/1- 14--- ����� Address) the /yeA-A—Alame) to hold temporarily and . the body (Unlertaker on ving charge of corps )',i (Inter, rem ve, or otherwise dis se of (state how)) Dated � 19..'�lI- " (Signed) This Permit is sufficient for the Removal (and Interment or Cremation) of a bod t ny pa of the ate (subject to local cemetery or other regulations),unless removal is by common carrier, in which case a T sit Permit (VS No. 62) is required. FORM VS. 61. (REV. 6/63) (6A2-130) I ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of`� was a—e?k--Zf19 77 (Interment or Cremation) (Name of Cemetery, Qa:an tePitt ebe-)—�-- Section ��"° Lot No. Gr e No. - (Signed) (.....--- -42117 -1--w7r/ (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, .- or r. SEXTONS, FUNERAL DIRECTORS and UNDE TAKERS violating the law relative to the return of per are liable to a penalty of NOT LESS THAN FIVE D ...40, LARS NOR MORE THAN FIFTY DOLLARS FOR TILL FIRST OFFENSE. The law will be enforced. Local Regis4 trars are required, under penalty, to report violations thereof/ -- !W YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT nr 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 CERTL FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ,J Registered No. Town, Village Dist. No. __J '- / County or City If city, give street address) Name of deceased C Veteran (If veteran,give name of War) Single,married,widowed, O Sex �� or divorced (write the word) Date of Death �z fib,--- 19.2 Age R( Years Months Days Birthplace __'Me—4.w-- r 1i-.M ' Cause.of Death Certificate was signed by M.D. Address Place of Burial (or Removal) 0. (If body is to be for orarily held, fill in space later) !/ Cemetery 11.,nr- - -T— ...------ Date of Burial I It 19 (If body is to be temporarily held, lill 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 registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE- BY GRANT A PERMIT to Imo, .- ..i l0w---4—___ (,3 C s41•V. — ,/'- >2,e4-- -- (Name) (Address) the to hold temporarily and the body ( nlertak or person having charge of corpse) , remove, or otherwis spose of (state how)) Dated O- 3 19_-ik (Signed) --- 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) (6A2-130) ENDORSEMENT OF S 'TON OR PERSON IN + CHARGE OF PREMISES N WHICH INTERMENTS OR CREMATIO 'S ARE MADE Date ofsSe was '19 71?) Cr nter r Cremation ep...6ltA (Name of Cemetery, C atorium, etc.) Section � 4t Lot No. Grave No. (Signed) (Person in Charge) I 40 Address ,. Person in charge must return this Permit to the Re istrar 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.