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Heckendorn, Herbert VS 61 (Rev. 7/79) New York State Department of Health BURIAL — TRANSIT PERMIT Name: First Herbert Middle G. Last Sex Heckendorn Male Date of Death ct. 1 , 1986 Age83 Yrslf Veteran of U.S.Armed Forces,War or Dates No I,,, (1 Z Place of Dea ity,To n Village spital, I st ion Street Ad ress A i y off" U� ns Fall s G i ens I-a`l s Hospi ta� W Causes of Death:, ✓ Acute yoblastic Leukemia W Medical Certifier: N itl dr s A William N. St John M�.b. 464 GlenAd street, Glens Falls, NY 12801 Death Certificate Filed:City,Town or Village District No. Register No. 0> City of Glens Falls 3�� �/� Burial: Date Cemetery or Crematory Address IN Cremation: Oct. 4, 1986 Pine Crematorium Inc. Town of Queensbury, N' Removal Date Place Removed and/or Held Address O U and/or Hold: I:: rn Date Point of Shipment Destination Q Transportation by L1. Common Carrier: to QDate Cemetery Address Disinterment: 0 Reinterment: Permit Issued To:Name of Funeral Firm A dre s Re i tration No. Regan & Denny, Inc. , Qua�Cer� Road, Glens Falls, NY di883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above: f~ Address: c4 Permission is hereby granted t spose of the dead human remains described abo as i rated ,�7 W Date Issued /Q ..3 ��' o": a' istrar of Vital Statistics ''"atu�) District No. 6a/ Place his permit must be completed on back by the person in charge at the place of dispo withhb'fegistraar of u.al s tics1—.1"/ c r village where disposition took place. PUBLIC HEALTH LAW §4145. Deaths; burial and removal permits; disposition of remains. 1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made shall inter or permit the interment or other disposition of any body unless it is accompaniedpy a burial,cremation or transit permit,as provided in this article. 2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any transportation company,which permit shall accompany the remains to its destination,where if within this state, it shall be delivered to the pers''i in charge of the place of burial or other disposition. 3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of interment, cremation or other disposition. 4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the funeral director or undertaker shall(a)sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. 5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and name and address of the funeral director or undertaker, which record shall at all times be open to official inspection. ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES. �J I certify that the remains were disposed of in accordance with the permit on the reverse side on ©� �� /9/4 (Date) at 1/191 r> e -r»oc7 O r' / lJ iU n (.2 h cc-c (Place of disposition and address p ) Section Lot No. Grave No. -�-- : ✓ Signature Title