Shepard Sr, Francis e ILI Flew TUKR 3 I A I C YCPAKIMCNI U1' I'ICALIM
OFFICIAL BURIAL (OR REMOVAL) PERMIT
QW' 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. /
Registe a No.
/ / Town, Village
Dist. No. r _ County_---4�C1 or City
If city, give street address)
Name of deceased 'L,( Veteran
(If veteran,give name of War)
Single, married,widowed, yy��SexJ )&_ -t or divorced (write the word)/2/4-44.4.S... Date f Death _ _-- __-- /‘ 0_77
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Age 66_ Years Mont ,sue..-- Days Birthplace _.. '`�
Cause of Death - v-C—,C'1""'-_ 4./;_�2 --)
Certificate was signed b --‘• ?. M.D.
Address \ II2,6—g-- jJi AI
Place of Buri (or Removal) __ f
(If body is to Burp
t orarily hid/fi ce 1 r) / J
Cemetery--- __.i. lt.e t✓ �/ d Date of Burial /? 19.7.2
(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, a ter 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 t basis thereof I HERE-
BY GRA4.....,
to
i 3 �
(Name) (Address) ,
the to hold temporarily and the body
(Unlerta r or persb aving charge of corpse) (Inter, ove, or otherwise dispose of (state how))
Dated /y 19 2_7 (Signed)
al egts ra
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo y 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)
e
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of '-q----
Z.-f:L /i i-z-c-tt / was /,-�z/ /719 7 r
(Interrment or _
/
CT-c,-,_.,.
(Name of Cemetery, Creter#um, etc.) '---------
_.
Section IM-c Lot No. Gra No. "_
o
(Signed) '"'�'t- (( '�~! "�--'
(Person in Charge)e)d
Address
/ '�T
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.
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 at Male Age(yrs.)
Jerome TnnkA'1' ❑ Female 63
Place of Death (indicate •whether city, village or town) Date of Death Cause of Death
City of Glens Fnl is _'l (/?7 , Myonnrden1 Infarnt
Cemetery now interred Location (city,town or county) - Is body to be transported by common carrier?
,Pine View Cem Vault Town of Queens'hnrytip NY ❑ Yes No
State fully the final disposition to be made of body.
To be Intered
tattle of place or cemetery for final disposition Date of final disposition
Cemetery ► Wall i ffc)rd V K/l 3/77
Firm Name Reg. No. Address
Pott Funeral Se 'ce 01974 136 Warren St Glens Falls . NY
;Signet of Funeral Dire tor Reg. No. Date
`I AN
0h)162 2/77
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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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