Klock, Mae NEW TORK STATE DEPARTMENT OF HEALTH
It I 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. y�� .--
Register d No. fJ
Town, Village
Dist. No. S b 0!/ County � (- �� or City ,��
�- _ If city, give street address)
Name of deceased G(,,�v-___I� Veteran '
/ (If veteran, give name of War)
Single, married,widowed, /
Sex
r or divorced (write the word) __ t�� � Date Death OU 19/._
Age f • Yeas Months Days Birthplace Cl
Cause of Death
Certificate was signed _et.., M.D.
Address /6 1 er
Place of Buri 1 (or Removal)
(If body is to b mporarily hie I fill in pace r)
�� 19Cemetery ___ _-•� ��( Date of Burial__ _iIi _
(If body is to be 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 At in my Local R ord with the above stated Registered Nu o the basis `teof_I HERE-
BY GR A PERMIT � ///��
to l'' ��2°L
( ape). 7 (Address)
the f �'L to hold temporarily and _,�tc„/`�'- the body
(Unlertak or person having charge of corpse) (Inter, remo�c o otherwise dispose of (state how))
Dated =-,'l 19_2_7 (Signed) /►/f+o►
ar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to a part of the State s ject 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 was ?; / 19
(Interment or (`..ramatin,,)
( j7—'
(Name of Cemetery,Lrcm�ieriy xi ,etcc..)° ` jy
Section �cz Lot No. Ge No.
(Signed) /
(Person in Charge)
Address j i =+�
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 pernhi
are liable to a penalty of NOT LESS THAN FIVE DOWIL4
LARS NOR MORE THAN FIFTY DOLLARS FOR TV
FIRST OFFENSE. The law will be enforced. Local Regi
trars are required, under penalty, to report violations thereofI
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.
hereby request permission to disinter the dead body of:
Name of Deceased Male Age(yrs.)
' Female 88
la
Place of Death (indicate whether city, village or town) Date of Death 'Cause of Death
2/1 O/77 Myocardial Failure
Cemetery now interred Location (city, town or county) Is body to be transported by common carrier?
Pine View e `,a. i t Tn of Queensbury,NY Q Yes CZ No
State fully the final disposition to be made of body.
Interment
Nettle of place or cemetery for final disposition Date of final disposition
ion ., _4 .� r' , o-. .� - _- `? - , _f ;j
Firm Name Reg. No. Address
Signature of Funeral Director or ndert er Reg. No. Date
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter X►II, 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.
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