Winer, Isidore � .
Forin 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
Male Age(Yrs.),t�} Female 70
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
°7
6 Hc,art Failure
Cemetery now interred� location (city, town or county) Is body to be transported by common carrier
` ` ?
J View {ec =� i. Tn of Queensbury,N.Y. ❑ Yes No
•
State fully the final disposition to be made of body.
Interment
Keene of place or cemetery for final disposition Date of final disposition
eth _1` Cemetery, Tn of Moreau N.Y. +;: /7
Firm N.,s,e Reg. No. Address
Re =: n & Denny, Inc. 02883 Quaker Rd. ,Glens Giens Falls, N.Y.
Signature of Funeral Director or Underta r /) ///(/r+ Reg.
ReNo. Date
7/ ' ..
•
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.
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT •
NAME OF First Middle Last DATE Month Day Year 1
DECEASED OF
(Type or print) Isidore (Nmn) Winer DEATH February 7,1978
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY HOSPITAL OR
Sarasota Sarasota INSTITUTION Memorial Hospital
Attending Physician LI (Name of Medical Certifier) (Address)
Medical Examiners 0 Dr. Murray Gray 1880 Arlington St. Sarasota,Fla.
Funeral (Name) (Address)
Home Robarts Funeral Home,Inc. 22 S.Links Ave. Sarasota,Florida
Check A 0 A completed certificate of death accompanies this application.
One
B n Dr. Murray Gray was contacted on February 7, 19 78
He has assured me that this death was from natural causes and that he will complete and sign
the medical certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by
on , 19
(Sig ature) 1 (Fla. Lic. No.) (Date Signed)
Funeral �,
Directo �i � c)6 I/ February 7,1978
BURIAL TRANSIT PERMIT Permit
No. 185-78-51
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For
cremation a waiting period of 48 hours after death must be observed and the Medical Examiner's approval must
also be obtained.
M A five day extension of time for filing the death certificate has been requested and granted.
Signature of az.4--#
,g Date
Registrarr' Issued February 7,1978
CEMETERY OR CREMATORY
Method of Disposition Date of
ir
❑ BURIAL Disposition L �����/�
❑ cREMATION
STORAGE Place of -e. (/66./' �� j�
❑ OTHER (Specify) Disposition !�
Signature of Sexton
or Person in Charge (2 . 1
:r4--1-E----kk_____
This permit must be endorse by the sexton or person in charge (or by the funeral director when there is no sexton)
and returned within 10 d�a to the local county health department.
HRS Form 326 (1/77) •