Harding, Gladys 0. im. NEW YORK STATE DEPARTMENT OF HEALTH
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /,
f-, Town, Village Registered No. �S
Dist. No: } County.-..L f1 a Ni or-ity- i-)a " ,i1
� (If city, give street address)
Name of deceased C.�-`A dry k. 6.P d i N Q Veteran
CJ (If veteran, give name of War)
,r� Single, married, widowed,
Sex rc%0ri t`1A....or divorced (write the word) IY1 P k.1. Date of Death K - i 19
Age q L..Years ...L?...Months / �S Days Birthplace U• Ji
Cause of-Death.file�-i v e Pc- hf'l Q Aiiet'P4 '.t'fq kc ki La tr.(4. 4o/a �' 0�- r ciJlel.c�vc4lz-.}` /7'"i ..t: "
Certificate was signed by F' '-'4k'f" N C M.D.
Address L1---'4--0- '-r1.;K b0-P. I.. :.6-,,t'•l.I S'
Place of Burial (or Removal) Pi& = t-t le e C . C.).fl Gc Li' tie r hl-.d'
(If body is to bg{emporarily held, fill in space lacer)
Cemetery----I'clti- .1' C.SW.)<- t N y Date of Burial 3/-2 19 '7 2
(If body is to he tempor'trily held, fill in space later)e"
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT Re.,45 ,,t,; .i b<_, wJ, , . _v\-e-.
to 1.%n'1A IC O ..101c= 't 6fee-Lc Ji- 'i /
(Name) (Address)
the -k-NkI -f _73.4.: :. to hold tem ora 'ly aid -I---N-4-Q( the body
(Undertaker or person having charge of corpse)
(Inter, remiove, cpt.otherwise disp ef [state how])
Dated �'V1;: = /,..... 19 `7? (Signed)..- .1 `T;•-tic.t-- -- ,sti`O-� y
-
Local Registrar
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) (3A2-323)
a ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
} CREMATIONS ARE MADE
Date of , - Was _19_
(Interment or Cremation)
i
1' } '
(Name of Cemetery,.Crematorium, etc.)
Section r Lot No. G o.___.__4
n
(Signed) - - } mil 4 i' V' Ze---i-t�•r-c- ..
'1 (Person in Charge)
Address ` / �_I � .fin r --
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 UNDER-
TAKER 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 Dis-
trict in which cemetery is located.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law
will be enforced. Local Registrars 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.)
Gladys Harding Female 47
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
Town of Bolton 2/27/77 Cardiac failure
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Rec. Vault Tn of Queensbury O Yes Ail No
State fully the final disposition to be made of body.
Interment
Name of place or cemetery for final disposition Date of final disposition
Bolton Rural Cemetery, Tn of Bolton, N.Y. 5/5/77
Firm Name Reg. No. Address
Regan & Denny Inc. 02883 Quaker Rd. ,Glens Falls, N.Y.
Signature of Funeral Dire¢t r or U ert ke'r f Rig. No. Date
04794 5/4/77
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter XII/, 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.