Lewis, Ruth VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
Name: First Ruth _M.Mi Lewis ddle Last ?MI-tale
Date of panh. 2 5 , 19 8 4 Age6 5 If Veteran of U.S Affirmed Forces,War or Dates
I-, �1 1Y( } spit
WPlace of Death:CheI7eoCtdCly Village St . Elates st too or Street Address
A Causes of Death:
ua Cerebral Vascular Accident
U
AMedical Certifier: Name Dr. Lu Title 2184 Dal ? Lane , Schenectady , NY
Death Certificate Filed:City,Town or Village District
4601
Register No.
Schenectady
Date Cemetery or Crematory Address
at Burial:
❑ Cremation: Spring 1984 Sealey Cem. Queensbury , NY
Z Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
E■
Date Point of Shipment Destination
Q Transportation by
a ❑ Common Carrier:
N
ODate Cemetery Address
Disinterment:
O
Reinterment:
Permit Issued To:Name of Funeral Firm A dress g on No.
Griswold Funeral Home 186! State St . , Sch'dy ,NY 616ti
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
(--1 Address: .:
c4 Permission is hereby granted to disp9 8 ose 1!1of the dead human remains described abo
a Date Issued Jan. 27 , 1 4
•
District No.
4601
Relies LtA I tics ( • ru rk
Place
his 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 vill•
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 py 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 destihation,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 aerson 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 shill 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 oh the reverse side on / /Z y
( te)
at 's�+. .' coo? i'
(Place of disposition and address)
l Section ,fgAni'i /+0 / e Lot No. Grave No.
,
Signature 1,1
Title
1