Strempel, Cynthia • ---4. NEW YORK STATE DEPARTMENT OF HEALTH
.. . OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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. / -_-
i Registered No.
.56�'7' �Ce 2�, �/ Town, Village x_e_- _ -�
Dist. No. County or City
(' \ j t If city, give street address)
Name of deceased -. - - ..- cam✓ `c✓ • ��-� r� -e Veteran
(If veteran, giv name of War)
yy Single, married,widowed,
Sex.— �1 -� — or divorced (write the word) Date of Dea )j 19.1?
Age L' 7 Years .-_ Month / Days Birthplace /
Cause of Death --t --_ .0 .. > •c, -z�i - e-l-•
Certificate was signed by r ,c c :.: -.- --- _ , . M.D.
Address 7. x=_
,.
Place of Buri�•Y�(or Removal) ,c,Y.2f. c.� re.-e.-2...c.� a
(If body is to bg, a porarily h/�1¢, fill in spac er) �/ -.
Cemetery (/. L--1_,L..�<i., _r�, , ," .'�� Date of Burial 19_7-t"
(If body is to lib temporarily held, fill ins ce ater)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, a7 _,--7
careful examination,
the same a-3 earing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registr n, have recorded it in my Local Re d with the above stated Registered Number, nd on tlw basis thereof I HERE-
BY GRA AIFTRMIT l l / //
LtO amp'' n (Address) /
the �i� :L � .� j • to hold temporarily and --- - -- y� the body
(UnlertakerAr p rson having charge of corpse) (Inter, ve, or(other��. disp se of (state how))
Dated7 19 e... (Signed) !\
Local ltegi: ar _j
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the a e (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. 6i631 (8A2-781
A ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of �" .N, �7 --47 19
(Interment or
(Name of Cemetery, Cre Istoslum;".)
Section Lot No. Grav o.
(Signed) --' � � f?/ •
t (Person (n Charge)
Address /"�tl !
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.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
E 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
County
No. `l^'OV` " or City `"`�—)- LI__
If city, give stredt address)
Name of deceased C1i )GL �� Veteran
(If veteran, give name of War)
Single, married,widowed,
Sex or divorced (write the word) Date of Death 19
Age ? )G Years Months Days Birthplace
Cause of Death
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body is to be temp raril,held, fill ins •ce later)
'Cemetery Date of Burial 19
(If body is to be temporarily Id, fill in spade a[er)
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
(Name) (Address)
the to hold temporarily and 7,) the body
( nlert er or per on having charge of corpse) (Idler, move, or otherwise dispose of (state how))
Dated )--3 19./`) (Signed) 0- e—se,�-
Local Registrar
This Permit 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. 6/631 18A2-781 )
K
'ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
I
Date of , , iw as ` / 19 Gj
(Interment cot Cremation)
1 ,
(Nameo emeteryCrematorium, etc.)
Section Lot No. Grave No.
(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
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.
114
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
/o'''f Deceasedi < 51 Male Age(yrs.)
(_ 7is ,71ta J I�Can,/ ed Female P�f
Place of/Death (indic to '•i, ther city, village town) Date f De th Cause of Death
C ettery now interred �,�, I,oc.0 on(city,town or counJpy) Is hody to be transported by common carrier?
/ yL I6 /G/w� t'.Vr Yrti/l i ''"*l a,4,ee r3 4;f/��// 0 Yes 0 No
State fully the final disposition to be made of body. /
-; 4,, ihkrrJ
Kam of plaje or cemetery for f at disposition ,,,/r Date of fi a dis o ttion prFi awe, Reg. Wo. Address
e C.,I Cy eCt.ti -, e7 "A Ii---, fil'vki (a S L#--ry Y . 1 _
R ' Fi/bierit 1--C:rAilec .,' -//
,slgnatur. of 'uneral Director or U rtalter ) ' Reg. No. ` Date
It/14 277"
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter xlii, subdivision 4) of the Sanitary Code, relating to the transportation of dead hod!'
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.
A