Viele, Baby boy B orn1-67 (rev. 1l/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: .
Nome of O teaser{-, / r�7 Male Age(yrs,)
j .t t' I '., , / 1 &. A �) 0 Female l /i r • -
Place of De th (indicate•'hether city,village or town) Date of Death Cause of Death
ti
L,i P7 1 r ,% )•c,47 f/ f 7ii
� I h�r E z �, bit . 1 ir z d``�
Cerceterynow interred Location(city,town or county) Is body to be transported by common carrier./
yI 1 ) 'r dYes ,
1 1 f.�t 6 r 4:«. 4S t.i t •�' �i . /�.i -fL , c'.�w a A,.." V `� �/>/ 0 � No r
State fully the final disposition to be made of body. /
Tb 6C j 1, i-Lr--c
Name of place or cemetery for final dispo jtlon J Date offl al disposition
rL Jf .
lj r.i�, 4g f. i•Ft Y! ". {i ` /;iL 'L / 'd VcGy 4 L �- /T
Firm0Na . Rag.No.
/ Address
,signatur /of }'unera ;Dtrertor,�r 4-er
Reg. No. pate''r
—.//le/iK 4 .
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.
new 11 V KK J 1 A I E NEI'AKTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
EF This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Dilikct
(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.
7,,f;:ric7t, L Village ����l!
Dist. No. .---/-6 i County/ ! —�"` —/)�
,/� If city, give strut address)
Name of deceased ,lcy'`___ ________ _________/._�� Veteran
(If veteran,/give name of War)
Single, married,widowed, �-�y j
Sex or divorced (write the word) _ �'C ! Date of D ath 19Z
v
Age Years Months --- Days ,_/Birth lac
Cause of Death - ___ '(/Le._.- E-z--s.,
Certificate was signed by ,/1�';___ -__- M.D.
Address � �
Place of Burial (or Removal) _./ G '
(If body is to be temporarily held, fill in space-later),
Cemetery 4' _ la-b'- L- ate of Burial 19__
(If body is to be temporarily held, fill in spice later) t
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, er careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registrati n, have recorded it in Local Record with the above state Registered Number, and on the basis thereof I HERE-
BY GRANT A .3E MIT
C_
to /777/—Z ' __) )----(-----z--L-- ----- 'e----
7411c_
(Name) (A re s) - �.
the to hold temporarily and �' the body
(Unler r or person havinig. charge of corps sd ,-- (In -remove, or oth • ispo w))
Dated ws 19_.. l6" (Signed)C�2 —
j Local Regis rar
This P mit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to lot
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
M 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 '✓ "ate% ''l was 19 7
(Interment or Cremation)
(Name of Cemetery, C
Section �� Lot No. Grave1 � 10
(Signed) '�� �L'- a�� r�✓
(Person in Charge)
Address 7X/
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.