Kietzman, Joseph New York State Department of Health
BURIAL — TRANSIT PERMIT
/Name:First Middle Last Sex
Joseph Lawrence Kietzman Male
Date of Death Age If Veteran of U.S.Armed Forces,War or Dates
E-4 August 19,1980 53 WW II
Z Place of Death:City,Town or Village Hospital, Institution or Street Address
w Sabael , Town of Indian Lake , Mountain View Camps
A Causes of Death:
U Probable cardiac arrest, Coronary Artery Disease
W Medical Certifier: Name Title Address
A J. H. B. Foote, M.D. Indian Lake , N.Y
Death Certificate Filed:City,Town or Village District no. Register No.
Town of Indian Lake 2053
/ Burial: Date Cemetary or Crematory Address
August 21 , 1980 Pineview Cemetery Queensbury, N.Y.
0 Cremation:
Z Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
E-a
cn `-Date Point of Shipment Destination
Q Transportation by
a ❑ Common Carrier:
A Date Cemetary Address
Disinterment:
Reinterment:
Permit Issued To:Name of Funeral Firm Address Registration No.
Singleton Funeral Home 314 Bay Road, Glens Falls,N.Y. 02285
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
1: Address:
rx Permission is hereby granted to dispose of the dead human remains described above indicated
a Date Issued August 20, 1980 �.�s� �o
Registrar of Vital Statistics (Signature)
District No. 2053 Indian Lake, N.Y. 12842
Place
This permit must be completed on back by the person in charge at the place of disposition and filed with the registrar of vital statistics of 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,by 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 all1 ii "
t// (Dater)
at Q✓l01'+.—•P Y -UL� T !!
(Place of isposition and addres
Section Lot No. .�j`? Grave No. /
Signature Title