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Persons, Bessie ! IrCYY TVKK 3IAIC YCYAKIMCNI OF 1'ICALil ""'s, OFFICIAL BURIAL (OR REMOVAL) PERMIT iSF 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. Registered No. _-?c. Town, Village Dist. No. - t1 County-_ \ ,,,.- or City - r-,Cc� 'D If city, give street address) Name of deceased Veteran ,© (If veteran, give name of War) Single, married,widowed, Sex N' ^S'I\ q.. or divorced (write the word) 1�sC:_C _-. Date of Death - _,_\;::3 1977 Age Years Months Days Birthplace __(\.....S1)...t,.) � %., Cause of Death ` Nic_ Z..,. Certificate was signed by , .___ Sr M.D Address D 9- ,arm CCIzrr ., 1Jy Place of Burial (or Removal) CDC.)- 0 '----\ D (If body is to be tem ily held, fill in space later Cemetery <ri.,Q- - -- C v Date of Burial __-__a%--- , 19 7 (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 registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE- BY‘GRANT A PERMIT to §s•� ,c _.' ..r�cN. _ i� i`.S —� _.C�L ^s �s —7 (Na e) (Address) the - to hold temporarily and S.2-^C\-N � the body (Unlertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how)) Dated ._ ___ 191 (Signed) . ate^ 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) (4A2-179) w ENDORSEMENT OF SEXTON OR PERSON IN 4 CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of was 6,�1-- 19 �/ (Interment or o-....9tinnl 6 7-e---/t-e‘ I/"---e-ee.er (Name of Cemetery, CJlftFfCib!' .) 1(/ -- 471v/11; Section Lot No. Grave No. (Signed) "- (Person in Charge) 496- / ,e,e Address 1 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 permits are liable to a penalty of NOT LESS THAN FIVE DOL- LARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Regis- trars are required, under penalty, to report violations thereof. t ta. 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.) Bessie Persons Female 90 Place of Death (indicate .whether city, village or town) Date of Death Cause of Death City of Glens Falls 2/6/77 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,N.Y. ❑ 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 Bolton Rural Cemetery,Tn of Bolton, N.Y. 5/5/77 Firm Name Reg. No. Address Regan & Deny Inc. 02883 Quaker Rd. ,Glens Falls, N.Y. ;Signature of Funeral Pir ct or U ertaker Reg. No. Date 04794 5/4/77 INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER: 1. See Section 13.1 (formerly Chapter XI►►, 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.