Newmark, Fanny In
F4 ,. '.5-1,/ (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�'Deeeased 0 Male -Age
rL $1 l { 11 ` �l /lAI
[..Female A 4
Place of Death(irjlicate mhether city, village or town) Date of Bath Cause of Death
14l.IS;41 t ill ify c;,/-1&--- 1.1? ) /4/, /4--- L_F
Ceq:etery now interred / ' Location (city,town or county) Is body to be transported by common carrier?
) - 1r 0 Yes [RI No
State fully the final disposition to be made of body.it
ir
r:a.1 of place or cemetr/4.,p io �ery forj,,rin 1 dissiosttion .... Date of (In 14dis ositfio
441
Ftr N-i a / Reg. No. Address b' •
e'l ii:t (r s / tt:-5 1 �*!" `� tV(.Ci) � �ts►3 i�5 i y �%1'f4j�
;Signs a of funeral Dire toror nd Reg. No. Date
ly) ofre/"."
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 YORK STATE DEPARTMENT OF HEALTH '
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred after the FILING and acceptance of a ORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 3
/ c f— / Town, Viltagc Registered No.
Dist. No. !°3 /`.� ,C9unty ��-�1-c f S or ety- ott c. )g: e- S I!z
f city, give street address)
Name of deceased F-74 A/N..t.,e-, Ale W rn/q,e< Veteran
s (If veteran, give name of War)
Single, married, widowed,
Sex Fah"A-- or divorced (write the word) '"7/ Date of Death 19 .2.e..
Age O Years _ Months / — ,Days i Birt ace. kil..jJ;i1
Cause of Death Years,‘
Sc-`-f( i.t5'�tQi9-�� �-//i.ee.
Certificate was signed b "+- o x S Y/1 ,9•J
F,n by-," �1. .. M.D.
Address ..AAt ....... )...�` u A.5 ..e . '-S/ 4 /V4 - / L4RO f
Place of Burial (or Re oval l(�'u/11 L 7 /f `/
(If body ist betemp_o, r'lyhed illtos a a r �
Cemetery ./,., ... ./..e �� _.. Date of Burial �)'' 19 7(If body t. to be temporarily held, ill in spg4e 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 registra-
tion, have recor ed it in my Local Record with the above stated Registered/Number, and on the basis thereof I HEREBY GRANT A
PERMIT /eto �s �i9/fie r ...)/ . L di" 0 )
d / (A ess) /�f j�i
r � e)� ✓/
the `—t/u .Q.PKO/Z_ to hold temporarily and t/ /I f t the body
(Undertaker or person hav ng charge of c se (Inter, remove, r othervis disp a of (st to how))
Dated / /0 19 ... . (Signed) /L ' I Z. . T_ n�
ocal Registrar
This Permit is suffici t for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local cemetery or
Cher regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
S. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
---C2X-41P-1Date of ��0 was �� //19 7
(Interment or Cremati n)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. G e No.
(Signed) ,_:) 14 CT
(Person in Charge)
Address % , e/
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.