Declos, Adeline vo of (Hey. ilia) New roric estate uepartment or rteaitn
BURIAL — TRANSIT PERMIT
Name: First
9 , Middle Last ,. Sex i
.v ��� ��2a Dat f GYPeDeath Age If Veteran of U.S.Armed Forces,War or Dates
H /74 f 7 /7f 7 7 ,�---.
W
W d=-C
of D ath: Cit�'Town or
Il e Hospital, sti u on o tr et dress
a e of esath
N dicaI,C rtifiet: N�a v / Title Address
Q C;(,- E.e',�L-�l I�n-0-, tlS-u.4_ ti42 -S-'�-elrsv�4.LG� 4e iNV -
Death Certificate Fi ed:City,Town or Village District Nd Registers
Burial: Date d Cemetary of Crematory �- Add e s
0
CI Cremation: /27
- `l —�
Removal Date Place Removed and/or Held Address
O and/or Hold:
v) Date Point of Shipment Destination
p Transportation by
is. ❑ Common Carrier:
rn
Q Date Cemetary Address
Disinterment:
o •
Reinterment:
Pit Iss}�d TD:N of Funer t Firm Address Registration No.
1 1.�i9fo"teb4 € d .e a�ss� J..Le K'lft'f e, d t Ff J-13%'.
N�meoi l uneral irm along ispositio or to/Whom Re ains are hip an A ove: 7''
F, Address:
aPermission is her y granted to dispose of the dead human remains described abov s indi ted ( j J
W Date Issued GI l/ 2-f"- i
p" / Re stray of Vital Statist' (Signature)
District lC//
Plac � /--',,e4
�This permit must be completed on back by the person in charge at the place of dis sitio n filed with thear of vl statistof the city,town or village
where disposition took place.
. PUBLIC HEALTH LAW
§4145. Deaths; burial and removal permits; disposition of remains.
1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompanied ply a burial,cremation or transit permit,as provided
in this article.
2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before
interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any
transportation company,which permit shall accompany the remains to its destination,where if within this state, it shall be delivered to the
person in charge of the place of burial or other disposition.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the
funeral director or undertaker shall(a) sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the
words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is
located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES.
I certify that the remains were disposed of in accordance with the permit on the reverse side on 6/10/80
(Date)
at St. Alphonsus Cemetery, Luzerne Rd. , Glens Falls, NY
(Place of disposition and address)
Section I —A Lot No. A-5 _Grave No.6
Signature Title Pastor