Akins, Harold NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tgr 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. --
, ...5
Registere , No
Dist. No....56/- County 6.../ ..„..ArA/„...14. Town, Village
or City
(If city, give street a ress)
game of deceased ..... Veteran
(If veteran, giv name of War)
Single, married, widowed,
Sex ?.. a--e-a— • or divorced (write the word) Date of Death 19 713
kge 70 Years ' Mon hs Days Birthplace 17- -
2ause of Death
:::4
certificate was signe 'by .,. c". . M.D.
'.4.--7
Address1°T1.
Place of Burt or Removal) ..
If body is to emporarily.4kld,6Z a e ayer,142
-emetery .....',..64, )........C,(44144' ....42:ekz, t/.
p
.. Date of Burial //- 19 77 _
If body is t he temporarily he d, fill in space later)
['he 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-
ion, hay ecorded it in my Local Record •i the above stated Registered Number, and on the bas- thereof I HEREBY GRANT A
'ERMIT
.
0 )4
me) (A dress)
to hold temporarily and r, re ve, or the body
he (Undertae(11Terson v.. char e of coj se)
)ated / iig g 19 #.7P (Signed) ) .Z?) her ise dispose of (state how))
ti..A...,4- i
Lo al Registra(
This'Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part ot the State (subject to local cemetery or
ither regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/631 (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHAK(ir:
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
/Date of 4.* was 19
(Interment or C-remaliola
(Name of Cemetery, Crematariumr-ete.)
frn
Section 1' / of No. Grac 7
(Signed) / z
(Person in Charge)
Address "' / -�. /te-o ''
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.
• .-,t,, 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. __ County7 or City
�/ If city, give street address)
Name of deceased "�'�e Veteran
(If veteran, give name of War)
Single, married,widowed,
Sex or divorced (write the word) Date of Death 3 19 ') 7
Age 11-- 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 eld, fil in sp a lat
'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
(Name) (Address)
the to hold temporarily and the body
(Unlertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated (")^'' -‘--- *( 19--.2-7 (Signed) E ''`''( c_p__`-e__.__
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. 6i. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
t CHARGE OF PREMISES ON WHICH INTERMENTS
`; OR CREMATIONS ARE MADE
Date of CyyG L-was --Y'
h 19
(Interment or Cremation). •
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) / &. /1--
cs...
(Person in Charge)
Address � � �7 G� ` I
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. 1l/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: .
hl4me.o1 Oeeeap 7 'k tale Age(yts.
flare l ` /. \et:1 0 Female
Place of Death(indicate whether city,village or town) Date of Death Cause of Dee h
evig
Cegetery n w interred Location(city,town or county) - Is body to be Ira,sported by common carrier?
�i C. r�W t�.� t ,,, leiC' a N 0 Yes No
State fully the final disposition to be made of body.
.7--; ahC �Gr �it C
M1attr of place ce:net�lortinal ispositl� Date of ll disposition
ille
fic C.
Firrr,Wa Reg. po. Address
� �� rvo Cr,a i ' , ") 0/rig (3 C Y -Yr�,1 ,- /e s r;4- 4'7
t/
19_ n e Rem pate
frir/77
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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 bodie
by common carriers, as printed on the back of the Transit Label.
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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.
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