Cutler, Hazel s w, NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No. /0 . •
Dist. No. . 601 County Warren or City City of Glens Falls
(If city, give street address)
Name of deceased .Haz.el....E., C.ut.l.er Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex Female or divorced (write the word)Wid°Wed Date of Death 2"22 19 7?
Age 67 Years Months Days Birthplace New York State
Cause of Death Acute myocardial infarct
Certificate was signed by Paul...N. Bulo.va M.D.
Address 50...Elm...B..t....„Glens. Falls.,NY
Place of Burial (or Removal tQWn....Q, ue.ens.bury.,.N.ew....York
,If body is to be temporarily he d, fill
j'in space later)
=emetery Fine View Date of Burial ..2/25 19 77
:If body is to he temporarily held, fill in space 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 registra-
:ion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
:o Regan & A.enny..,.Inc. .Quak.er F �.Bd. ,G�.en�...da..s.,.N.a.Y.R
(Name) (Address)
:he Undertaker to hold temporarily and r..emoval the body
)ated ndeuct#�75.per n having charge of P ) (Inter ove, ojjerwij e dis ose of (state how))
a� 19 . ..... (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an art of the State4sutriect'to local cemetery or
)ther regulations), unless removal is by common carrier, in which case a Transit Permit ( S No. 62) is required.
'ORM VS. 81. (REV. 6/83) (9A2-205) 9)
"' ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
v
Date o itFi was J� ' S 19 27
(Interment or C®'n,4i^4)
J/-K-e- I" .�L e.i,c!"1
(Name of Cemetery, C ' m, etc.)
v. gay*/ AZ
Section Lot No. Gr e No.
\I. / .
6/
(Sign
ed)4
(Person in Charge)
Address /k / _< / .
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 UN
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge," a
FILE PERMIT WITHIN THREE (3) DAYS with the Regis*
of District in which cemetery is located.
4
SEXTONS, FUNERAL DIRECTORS and UNDERTAK
violating the law relative to the return of permits are liable a penalty of NOT LESS THAN FIVE DOLLARS NOR MORi
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.
J
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 8 Male Age(yrs.)
Female
b
Place of Death (indicate .ohether city, village or town) Date of Death Cause of Death
.r r / =, , Cardiac failure
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Rec. jv a'..i, __ of e .n- ,7,'... '?:d. _ . 0 Yes cl No
State fully the final disposition to be made of body.
Interment
Name of place or cemetery for final disposition Date of final disposition
:a:''u'"} ic 'a etr,ry, Town . cr:e . 29'/ t'7
Firm Name Reg. No. Address
Regan Rx D(3i,
r;r, Inc, Quaker Rd. ,Glens Falls, N.Y.
'Signature of 1'unerarec r or erta 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.
c •