Henderer, Doris IIII NEW YORK STATE DEPARTMENT OF HEALTH
dole. NEW
BURIAL (OR REMOVAL) PERMIT
eSr 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. / r�
Registered No. /o J
— . Town, Village
Dist. No. (0-� / ounty A--&-A--------/,z or City .
If city, give street address)
Name of decease -"`��e/� Veteran •--
(If vete an, give name of War)
Single, married,widowed,
Sep.' L/ l< � or divorced (write the word)7166-4A -fie Date of.Deat - 69 19..7_7
Age ---- 3-__ ---_-__-- rs Mo the Days Birthplace s
Cause of Death
Certificate was signed by _-I( _ - GL- � M.D.
Address e G .
- - -
Place of Bur' (or Removal) M,G -f�c.�a_._ __ - _ 4
------ ---- -
(If body is to b mporari eldi fill i e later) n
Cemetery_;_ /� Q L¢�-�; / ' Date of Buria'a� -2 3 19=7--
(If body is to be temporarily held, fill in ace later)
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 ation, have reco d it in my Lo 1 Record with the above stated Registered Numb r, and the basis thereof I HERE-
BY G A PERMIT '," ���
t0
-V / a
( ame)/ (Ad r s) /
the G - l • to hold temporarily and . VW .. '2,' the body
(Unle er r person having charge of corp a (I er, remov- .r otherwise dispose of (state how))
Dated_ -- _ --3 19. 2 (Signed) . Jc `
i car a 1st (
This Permit is sufficient for the Removal (and Interment or Cremation) of a body 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)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of v was ' -3 19 Y 7
(Interment or ation)
(Name of Cemetery, rirmi
Section r - Lot No. Grave No.
(Signed)
(Person in Charge)
Address
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 in
charge," and FILE PERMIT WITHIN THREE (3) DAYS
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
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 Male Age(yrs.)
Dori Ann Henderer Female -
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
(Ci
ty y oy Glens ,'. a__ ...._. 1 .=:sr Coronary artery d.-. eese
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Rec. Vault Tn o_ f _queensbury D Yes No
State fully the final disposition to be made of body.
Interment
Narfie of place or cemetery for final disposition Date of final disposition
• 2 Lio . r _a 4/29/77
Firm Name Reg. No. Address
Denny, I»c. 02883 quaker Rd. ,Glens Falls, N.Y. 12801
•
Signature of Funeral irect or U ert r Reg.No. Date _
( / - 04794 4/27/77
•
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.