Britt, Leo t"' 'I, NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rip- This Permit can be signed onl;. 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. E- a.
Dist. No. S C / County �'U`t't'`-'z-"-- or City r-- ' c/_.,_ r``.4�
/ (If y, give street address)
Name of deceased -•4 /77, /5,-r Veteran .. —77 0
(If veteran, give name of War)
Single, married, widowed, q
Sex /�o._-&... or divorced (write the word) a„-.0s.4.�..t4r Date of Death 7--<-0-• 7 19 77
Age 72. Years M .._Months Days Birthplace /2, ,...f,
�1�
Cause of Death /i 1(.�f:.0 c-R.-ir .(..r.)..-t. .a.L fr,-2�-
Certificate was signed by .L1$...+.�.... J.,....1J. Z..r _ M.D.
Address g.7._...7.. 0.--,.-4.......t.7-• / G/. ° —, ,5./
Place of Burial (or Removal) .... . . �C ,*tJ.7 c� _ /,, 'J,,., ,
(If body is to be temporarily held, tiff in space later)
Cemetery ,14."....r7..2;:.........(,,.0..:e ::: Date of Burial 'Yii 19 27
(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-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT I ti
to /� r� `„� ��, a.� (,�., �.r'/ C�/.ram. /� �� 27 Li
,..
,j � Tame)
( (Address)
the (/..Ltt.r:L. /1..- z-''-- to hold temporarily d ,1- -(-,4,:J.,,., i'-.4_ -^. the body
(Undertaker or persoo having charge of corpse) ter, r ve, therwrse dispose of (state how))
Dated �7/e 19 " (Signed) ;:� ... (
Local a rar
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 removol is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ROItM Vs. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of ' was �i //19 7/
(Interment or C3aem.tina)_
(Name of Cemetery, Crem feri.um,, a4c.)
Section V '1 Lot No. (Grave No.
(Signed)
v .
(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 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 District in which cemetery is located. ,.y
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.
- 1
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 Q Male Age(yrs.)
Leo M. Britt 0 Female
Place of Death(indicate whether city,villawe or town) Date of Leath Cause of Death
City of Glens Falls 2/9/77 Myocardial failure
Cemetery now interred Location(city,town or county) Is body to be transported by common carrier?
Pine View Rec. Vault _ ._ C f . . ..- 0 Yes No
State fully the final disposition to be made of body.
Interment
Name of place or cemetery for final disposition Date of final disposition
s :., Mary t Cerr t y , 62 2 Kiangp _ : 1 ./11/77
Firm Name Reg. No. jAddreas
Regan est Donny .Inc. 02883 j quaker Rd. ,Glens Falls, NY
:Signature of Fun rat'Dire or nde r Reg. No. Date
G� 04794 `r
i'
l . '
•
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.• Tr'is form should be filed and carefully preserved in your office.