Tucker, Jerome R III
IrCW TVKK JIAIC ULrAKTMCIVT WI- I1CALT11
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. /
Registe a No.
rf
Dist. No. Ol 0 + I 1 Town, Villa ge County te.) _ _ oTrowCity
If city, give street address)
Name of deceased 12 - , Veteran
(If veteran, give name of War)
Single, married,widowed, p
Sex_-_A“2 or divorced (write the word)/9/0-44.1.i.- -k Date f Death _ -.. __-- /e 19-77
Age 46. Years Mont ,s�_,.j1 Days Birthplace .---�2,Q .x)
Cause of Death - -d-�C'1""_'je_.
g:-zS..C-1s-
Certificate was signed byY ?• M.D.
Address .�- /~.d. 5 P46 /}& k
Place of Buri (or Removal) _._
(If body is to b t porarily h�;/fi ce 1 r) / G
Cemetery ___ __.�(Jkue (/ � _. (1 Date of Burial__.. _-_ __ // 19.72
(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 GRA, P MIT
to -- - -- --- - --- - -- - --1 3 ‘ IrZitAddress)
me)
the to hold temporarily and the body
(Unlerta r or persb aving charge of corpse) (Inter, ove, or otherwise dispose of (state how))
Dated 19 27 (Signed) ,_
l' lai egis 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)
C
ENDORSEMENT OF SEXTON OR PERSON IN
Z CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
' CA�L/ /719 7 Date of -� « was
(Interment or _ _.,
t_
(Name of Cemetery, Crefftatorium, etc.) "— —
Section � Lot No. Gra No. �Z
(Signed)
(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
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.
11164
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 ei Male Age(yrs.)
eTArn121A T13 1. r � Female 63
Place of Death (indicate •whether city, village or to vn) Date of Death Cause of Death
City of Glens Falls Wl V77 Mynnnrden, Infar�i
Cemetery now interred Location (city, town or county) - Is body to be transported by common carrier?
,Pine View Cem Vault Tnwn of Oneenshilryw ? Y 0 Yes No
State fully the final disposition to be made of body.
To be Intered
Name of place or cemetery for final disposition Date of final disposition
rrreAnhill Cemetery , Wall i fford V K/l 3/77
Firm Naree Reg. No. Address
Pott Funeral Se ece 01974 136 Warren St Glens Falls . NY
ISlgnet of Funeral Dire for r dJr Reg. No. Date
r oth62 c/12/77
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. This form should be filed and carefully preserved in your office.
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