Monroe, Francis worm -67 (rev. 11/65)
r
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 oA eceased ✓
//g ❑ Male Age(yrs.)
Li 0� 1/4:'- 1 i l C.'' 0 Female )
?lace of Death ndicate whet er ci y, tillage or town) Date of Death Cause of Ueath /
C,eyyetery c V�o+w interredr Lo n (city,town or county) ,(� Is body to be transported by common carrierI ?
1rlC l'`N.'L�B�.a rryI/ / d A., G
ivt7 t-`, .),j✓i �l').' y ❑ yes No
State fully the final disposition to be made of body.
l v 6-C- i h i'cr
Name of 1 ce or cemetery for final dispositi n Date of.fi al disposition
Fi cr�Na `.y 1 Reg. No. / Address
Sign � . of Funeral Pirector or- sf r R`g. r o. 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.
IICrlf IVKK ZIMIC u raKIromnI Vr rlCALIf
OFFICIAL BURIAL (OR REMOVAL) PERMIT 1,,
Q This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration l :trict
(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.
IS
Registered No. 4
5726 Washington Town, Village_udson Falls
Dist. No. County g or City
If city, give street address)
Name of deceased Francis G. Monroe Veteran No
(If veteran, give name of War)
male Single, married,widowed, Married
Sex or divorced (write the word) Date of Death ___Feb.__.i9_,__.___._._ 19 78
Age 80 Years Months Days Birthplace N.Y. State
Cause of Death Transitional Cell Carcinoma of bladder
Certificate was signed by Richar_d_.T._.H.orsan M.D.
Address 325__Main___St_.,__Huds.on_Falls.,._N.Y.
Place of Burial (or Removal) Glene__Falls,__N_J.,
(If body is to be temporarily held, fill in space later)
Cemetery Pine View Ce, Vault Date of Burial Feb. 20, 19 78
(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 GRANT A PERMIT
to Potter Funeral Service 136 Warren___St..,___G_lens..Fall.a*._N..Y_.
(Name) (Address)
the undertaker to hold temporarily and* inter the body
(Unlertaker or person having charge of corpse) I r, remove, or en is (state how))
,S-�j )
Dated Feb, 2_i, 19_.7.8. (Signed) �.�__ ��� ✓L� nP�
Local Registrar
This Permit 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.
FORM 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 was ,al
A 19
(Interment or. 'w" t'er) -
(Name of Cemetery, Cr444,94.,or-iusa-retc
Ae
Section Lot No. Gra3Qo.
(Signed)
(Person in Charge)
Address
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.