Heller, Otto 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.
egistered No. /2/
Town, Vil //
Dist. No. ,5-L�- Countyte./faic,„ 7„,.._- City / t i'�`'7 cit ive reef?7'.
d
Name of deceased fil,...tizer.„.L....„,
Veteran ' c-
(If veteran, give name of War)
Single, married,widowed,
Sex ___�._ _. __j,�,�Jc'�— or divorced (write the word) ���f�C-1sL�(- _ Date of Deat -_ cR. _ 19__..�—',
Age .� _, Y ars M nths ._.., - Days Birth lac '.- _. C.,
Cause of Death ____ _ ___ _ _ _ __ __
Certificate was sign .,.;_/."6 ‘, .
__ M.D.
Address
Place of Buri o Removal)' --
(If body is to be,temp aril-y hel , Pill in space l
Cemetery-__.___ .,,� ,_. . Date of Burial � � 19 "a
IL
(If body is to b emporarily held, fill in space later) r
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the sa pearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for gistr ion, have r o ed it in my Loca Record with the above st ed Registered N er, a on the basis thereof I HERE-
B G A R T .72
t —
(Name) (A res0
the _ Ct- - to hold temporarily and _-_ the body
(Unlertalter or erson h vmg charge of corpse}},, n remove, o other Ise d- of (state how))
Dated C 19_./.I (Signed) P',
'Local Iteg. r
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) (8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of `'' ` 19 7
(IInterment or Crematioa4
(Name of Cemetery, a c.)
Section Lot No. rave No.
(Signed) `2
(Person in Charge)
Address
`1 l
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.
t hereby request permission to disinter the dead body of:
Name of Dece sed ii Q Male Age(yrw,^
t (-Wier'
1///
K 1 er/ ❑ Female
Place.of Death (indicate whether city, village or town) Date of Death Cause of Death
I d 43WS1 C� 4" c Cr. a)dt�.-i.( f / .-/ i a 1 t M !.' d '�1 ',E Ble c f.4,
Cg�+�etery nno interred j,.oc ion (city,town or co y) Is o y to be transported by corn on carrier?
1—'.h e 'elt=�l.eivi Vit'w 7101el,ie !iis bury/HY 0 Yea No
State fully the final disposition to be made of body.
/r j
1 a N c i y'
Nettle or caiget�er�yr liaai�diap�osition 1` Dat�f ���spo�ltion
p!(itf‘Na Reg. Mo. Address , i/
fi- of Funeral A ctgY or-ti Reg.,No. pia- .//f
il
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.