Viele, Baby boy A 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 o Oe eased I / %/�� 13 Male Age(yrs.)__//
J at h— '�: V• 1 ' Z- �/.+A ❑ Female I `/ -
Place of Deaff(Indic a hether city, village or town) Date of Death Cause of Deal&
/All K ) n fr--Le.r.k.41 1 4:-/ BA I,k •
�.eter, w interred �,oc tion (city, town or count ) Is hody to be transported by common carrier?
1 ;NLfI 'e'/ LPr1 10/4' Lf- fdwl le" i ' eC.,S N:2 I( 7 / 0 Yes T�f�No
State fully the final disposition to be made of body.
bathe place or cemeteyy for fin I disposition Date of fina dlspoa lion
L' i 1
_// /� p
'►1i :wcrLl L. C 's� el �,r.y+a /7— /"� 0°ret:_ �/ p/ /'a' le-'
Firu:e p Reg. No. Address .J
l > , --- �'n C�t .J,e'frVt way-z-- L21-f 7 1 /3 < �z t'vr ,,, I 4-; e--7en_y /
Signature/ Funeral D,-r ore qke Re q. Date �.
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.
ncvv if VKR 31 A I C UtYAKTMENT VP HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT Vw..»
ItS9- This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Dis—et
(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. !
I
Registered No.
/ -Town,Village 6 � ,` _
Dist. No. Dn County qr City
C/`/ If city, give str t address)
Name of decea l e
�C/ Veteran ' ---
(If veteran, give name of War),.� Single, married,widowed, p
Sex " C�' or divorced (write the word) A�4ik-Dat of Death 1. 192C1---
'�,
Age Years Month$ Days rt�}pla e /�
Cause of Death =.....v, -c _ - /li , {
Certificate was signed by 4. --..--- -0- ,. ._ M.D.
Address
Place of Burial (or Removal) ) z
(If body is to be temporarily held, fill in space lat %�
Cemetery -G'-Z j,JU t'i ate of Burial ---!_ .-._f) 199.
(If body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to m , after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registration, h recorded it in my Local Record with the above stated Registered Nu b and on the basis thereof I HERE-
BYtoGRANT A �T 1 p-1 �^L� ti cc l Al�� ,� %. 41
(� (Name) / J//, (Address)
the to hold temporarily and the body
(Unlertakep or erson havicharge of corpseY (Inte remove, or erwise spo�9�' (at a how )
Dated ` 19 /// (Signed) GL 7 --L:7 C/ _ '"L--
Local Registrar
This Permi 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.
RM 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 71 was 19
(Interment or Cremati
6::-?.---1-c-e-- V...--C-e-e--c,---
(Name of Cemetery, Crematorium, etc.)
Section �"-"' Lot No. Grave N CO
(Signed) 1-91-14- a "?21-:----"e---'1"t--kf--/
6.-
(Person in Charge)
l'%
Address ,'L`
,e,
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.
IP .wM