Smith, Mildred formy'�7 (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 Decea e }(.// Male Age(yrs.)11 lt�t X. i . �r� 1 1 rl ®.Female
or
Place ofDe t (indicate whetherf�� city, village or town) Date
/of/Death Cause of Death
/4 1 ':4 i t+r� A N �/ //! �. Sit✓�(,�4�!+ (.t.t ;'
C metery now interr_d t, 1.oc on (city,town or Co y) Is body to be transported by common carrier?
• /, It c V t f:•i. (.. (,t4 t 4✓ r t�i1 f/G"Cols h../e J 1 ® Yes No _
State fully the final disposition to be made of body. /'
-s/ ^f ' (J
J l VI isc 44- -1 c l
halag„of place or ceinetery for final disposition Date of fl 1 disp sitlon
/c•►i ffk �eMc C ( �'E.. I A.,,,,„ /AL_Nrc..,. / y / /Y/71-
Fir Nathe- Reg. No. Address/ j 1 /� /� /�� /
Y ��ht✓s'( yL.j' t//I7 I _14 t1<(1--✓ch5/ r ly-ltet-) `t //)_ /• \!
S1gnat e f Funeral pine or dr Ur de Reg. No. 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. T he 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 YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ITS5P This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Dift:t
(Town, Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CEFr'I-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
/
Registered To. br
:-
Town, Village . 6
Dist. No. County C� y� or City l/"er•vzu�
O �) If city, give street ddress)
Name of deceased Veteran
(If veteran,give name of War)
rwc / Single,married,widowed, G,C ,�
Sex p '-' or divorced (write the word) Date of Death 64'1i ' 3 19 ?_,
Age 61 Years Moths Days Birth ac z 41,1,-...,i ,
Cause of Death �% -, c�ri+.ol. h+-e �^ ei,;.".,
Certificate was signed by f M.D.
Address Ca, l�_ t
)
Place of Burial (or Removal) (21.1..e,z,%,a l r ;
(If body is to b poraril held, fill in space later)
Cemetery L v t�i ' Date of Burial (//\J)e-1^ • 1 7 19 ?g,
(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, after 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 the basis thereof I HERE-
BY G A PERMIT
to -/- • .." ‘ , 06-n4 1714-eZ , /)1:7 .
(Nam?: , f (/ ress)
the / �r,� 6.1014.......44.1
�'d��'^ old temporarily and the body
(Unlert k r person ving c of corpse) (Inte remove,�y otherwis ispose a ho
Dated L2w . / 19 7/ (Signed) __L-�ie- ` zP
Local Registrar M `��
This Perm is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub ct to local
emetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
VS. 61. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN / Fo,
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of��?/1/1 ex� was / 19 7
(Interment or
(-3,- K:t;-0°-(CA--
(Name of Cemetery, Cr
Section 1 r-A-ft 1 1'- Lot No. tX OP
G ve No.
\.,. .kr-k -121Z----
(Signed) --(
(Person in Charge)
} ' jAddress / 1:e' 11 '
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.