Clements, Roy 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.
Town, Village
Dist. No. SC"S County or City
If city, give street address)
Name of deceased Veteran
(If veteran, give name of War)
Single, married,widowed,
Sex or divorced (write the word) Date of Death 19
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, fill in space later)
Cemetery Date of Burial 19
(If body is to be 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 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 a/� A"), s ' /p . S _. 1 '1✓ `"� �?v �'Q�
(Name) (Address)
the to hold temporarily and the body
(Unlertaker or person having charge of corpse) (Int
, , or otherwi dispose of (state how))
� j Dated ^'A ( 19 1 (Signed) move
U 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)
;t ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
17 2444d,j
,r
Date of was e 19
(In ermennt or Cremation)
.9.,-40;4,e%
(Name of Cemetery, Crematorium/a c.)
i
Section 2P Lot No. Grave No. _iii_____.
(Signed) tr
Person i Charge
e___...
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 1N-67 (rev. 1l/65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
/n 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 Age(yrs.)
� Male
Roy S. Clements p Female 59
Place of Death(indicate whtther city.village or town) Date of Leath Cause of Death
Tnwn of Wilton, N.Y. 12/2 /79 Acute Coronary insufficency
Cemetery now interred 1..ocation(city,town or county) Is body to be transported by common carrier?
Pine View Cer Vault . Twn Queensbury N.Y. 0 Yes Lai No
state fully the final disposition to be made of body.
to be intered
Name of place or cemetery for final disposition Date of final disposition
Friends Cemetery , Twn Queensbury NY 5/3/79
Firm Na.ee Reg. No. Address
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Potte Funeral Se ce 0197 136 Warren St 'lens Falls NY 12801
:Signet a s! Funeral r or r n3 rt Reg-. No. Date
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INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
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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.
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