Benjamin, Clayton s new WKIC 3 I A I C UCYAKIMCMI VP MCALTM
OFFICIAL BURIAL- (OR REMOVAL) PERMIT
This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District
(Town, Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. ‘
Town, Village /J�
Dist. No. ���% County or City - , r �����,
C , /- 4e-
city, give street address)
Name of deceased 4f�� _ ' 1 Q Veteran -
(If veteran, give name of War)
4d..6...
Single, married,widow& , -- i ��Sex or divorced (write the word) Date of Death 1 19 "77
Age Z ) Year Months ays , Birthplace ..? -
Cause of Death . _ t.-- ---- ,:-i.- -4.
Certificate was signed y - ' M.D.
Address 1j •
_
•
Place of Burial (or Removal)
-- -- --- -- --- ‘,..,._,Li.
(If body is to emporarily h ld, fill in spat r) �) p r
Cemetery_ Zi_ c,r�d-- —?—c • A/4i .bK-
_ti Date of Burial__ -1p' 1 19 � 7
(If body is to be temporarily held, fill in space I ter)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regis ion, have recorde it in my Loca Record with the above stated Re stared N mber, and on the basis thereof I HERE-
BY GR A PERMIT / � 1,--geo'
to �i2t 4A--. `" �"` .
(Na e) (Address)
the t:::-)l_ -(, to hold temporarily and ,- - the body
(Unlertaker person having charge of corpse) (Inter move, or otherwise dispose of (state how))
Dated -1- I 19.7__ (Signed)
MlRs ar
This Permit is sufficient for the Removal and Interment or Cremation) of a bo to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (4A2-179)
f
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date o i was '2—// 19 7 7
(Interment or 6cmation)
—�---tee..__
r /f
(Name of Cemetery, a ormm, et—ET—
Section Va-f-d Lot Na ' `7. Grave No.
(Signed) '.:Ai,s '-��r/
(Person in Charge)
Address B'e / �` tj�?
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date.
If no person is in charge, the FUNERAL DIRECTOR or
UNDERTAKER MUST SIGN ABOVE STATEMENT,
write across the face of the Permit the words "No person it
charge," and FILE PERMIT WITHIN THREE (3) DAY&'-
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UND- -
TAKERS violating the law relative to the return of perm` s
are liable to a penalty of NOT LESS THAN FIVE DO -
LARS NOR MORE THAN FIFTY DOLLARS FOR TH
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.
Form VS-67 (rev. 11/65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
In completing this form, please typewrite, hand-print or write legibly all entries in permanent black or blue black
ink. Signatures should be legible. This is a permanent record. When data cannot be obtained, write "UNKNOWN"
in applicable spaces.
I hereby request permission to disinter the dead body of:
Name of Deceased E3 Male Age(yrs.)
Clayton M. Sen ja)a x.n Female 87
Place of Death (indicate .whether city, village or town) Date of Death Cause of Death
City ofis _s 1/30/77 Congestive heart failure
Cemetery now interred Location (city, town or county) Is body to be transported by common carrier?
Fine View _..-c Vauit Tn of Queensbury 0 Yes c] No
State fully the final disposition to be made of body.
Interment
Nadte of place or cemetery for final disposition Date of final disposition
GraFy Hill Cem. , falls Villa e, Conn. f /"'3/77
Firm Name Reg. No. Address
Regan & Dp. ny, Inc, 02883 quaker Rd, ,Ulens Falls, N.Y.
;Signature of Tuners erect or Und Aker } Reg. No. — - Bete
�-- -- - 04794 4/21/77
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter XIII, subdivision 4) of the Sanitary Code, relating to the transportation of dead bodies
by common carriers, as printed on the back of the Transit Label.
2. The data required concerning the decedent may be obtained from the local register or cemetery record.
INSTRUCTIONS TO LOCAL REGISTRAR:
1. For bodies to be transported by common carrier, fill out Transit Permit.
2. For bodies not to be transported by common carrier, fill out ordinary Official Burial (or Removal) Permit.
3. In each case write the word "DISINTERMENT" on the Permit.
4. This form should be filed and carefully preserved in your office.