Clapper, Dale vs bl (Nev. ti i ) New 'fork state uepartmeni or rteaitn
BURIAL — TRANSIT PERMIT
/Name: First Middle Last Sex
Dale A. Clapper Female
Date of Death 7,1983 Age 36 If Veteran of U.S.Armed Forces,War or Dates
E4 U
Place ITGl VillageHospital, InliQn orHSrt tr�ssw City of enFalls Gens Falls Hospital
WCauses of Death:
✓ Liomyosarcoma with metastasis to lung
W Medical Certifier: Name Title Address
A William P. Simmonds, MD, 8 Harrison Ave. , Glens Falls, NY
Death Certificate Filed:City,Town or Village District No. Register No.
421 City of Glens Falls 5601
Date Cemetery or Crematory Address
Burial:
0 Cremation: Dec. 9,1983 Seelye Cemetery Tn of Queensbury,NY
Z Removal Date Place Removed and/or Held Address
0 ❑ and/or Hold:
E-
(7) Date Point of Shipment Destination
Q Transportation by
a ❑ Common Carrier:
cn
ADate Cemetery Address
Disinterment:
0
Reinterment:
Permit Issued To:Name of Funeral Firm A ss istration No.
Regan & Denny,Inc.,Quaker Rd.,Glens Falls, NY 02
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
E—. Address:
c4 Permission is here7granted
,dispose of the dead human remains described aboveX
W Date Issued � �f
a C Regi r ital States' i nature _
District No. S W� >/ - t�
lace -
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 N CHARGE OF PREMISES.
I certify that theremai \kr$ disposed of inladcordance with the per • a reverse si on
�—� ( --1 (Date)
at '
(Place of disposition and address).
Section Lot No. Grave No.
Signature Title