Dumas, James VD DI (r1ev. (I I IYGW I VIn V laic UG`JQI II cI It VI I IGCLI II
BURIAL — TRANSIT PERMIT
- Name: First Middle Last Sex
/ Jamec R. Dumas Male
Date of Death Age If Veteran of U.S.Armed Forces,War or Dates
Ei 9/17/81 40 Yes 1958-59
Z Place of Death:City,Town or Village Hospital, Institution or Street Address
w Town of Milton Emigh Road
A14 Causes of Death:
U Broken Back and Crushed Chest
A Medical Certifier: Name Title Add ess
J. Paston M.D. 211 Church St. Saratoga Springs
Death Certificate Filed: City,Town or Village District No. Register No.
Town of Milton 4561 6
Date Cemetery or Crematory Address
7 Burial: g/22/81 Pine View Cem. Town Queensbury N.Y.
0 Cremation:
Z Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
VI Date Point of Shipment Destination
Q Transportation by
a., ❑ Common Carrier:
rn
ADate Cemetery Address
Disinterment:
El
Reinterment:
Permit Issued To:Name of Funeral Firm Address Registration No.
Potter Funeral Service 136 Warren St. Glens Falls N.Y. 01974
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
E-4 Address:
IxPermission is hereby granted to dispose of the dead human remains described above as indicat ,n, /��
a Date Issued ,� sC1 .Sign
Regio ar of Vital Statistics .Signature)
District No. Town of Mi 1 ton
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 accompaniedpy 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 i/ A/?)
(Date)
at
(Place f disposition and address)
Section G2-1-1 et:clit, 264 Lot No. Grave No. /
Signature « Title