Leonard, Frances {
iFo it'S-67 (rev. 11!6S)
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.
f hereby request permission to disinter the dead body of: .
Name of Deceased Male Age(yrs.)
n
1i A01C 's e / ,-,,ci18 a //Oa Female ti'GJ
Place of Death (indicate'whether city, village or town) Date of Death Cause of Death
&C.:- r,LI� 7(117 /(/,4 1c?4 l (&H,�
Cemetery now interred
Location
(city,town or county) Is body to be transported y ommon crier?
P/h/e-j//r.::a./ /ey%'?,/e,e• 6--& T as-a y 0 Yes No
State fully the final disposition to be made of body.
Ir 4 c 1 tt1TE FAJ 7 .Z-iti /Li f /f}A.,47. �' ."ilh'71,6"V .
/0,_p,77g-fga v6 A i 7
•Name of place or cemetery for final disposition "O"�—'
Date.of float disposition
41 r Cp9- ,-, (_ i /i o ,5 er i ‘ X-'/` /-?!2 c mac-, 71 7,7'
Firtr. Na.ee
peg. po. Address
.J9?y - F sc 'c E-7-e A', 7c/C O o?Z J/ 119 y ke9c/ !mac ,Frets ,1 it Y/2sw
$1 Lure or f' er 1 treetor or Undert lker Reg. No. pate /
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 Officjal 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 �,
This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Dist .et—
(Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERT
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 77 d'ti
Registered No.
or City.-
?�i l "
Dist. No.�_�, 6' Count _ .. I(�'✓'�__. or Cit - r�-o
If city, give street address)
Name of deceased - 24--C___2___- ---:_ e--�L 1,--_-_ Veteran
(If veteran, ive name of War)
�/ Single, married,widowed, /�
Sex __�J `' or divorced (write the word) 1�R Date of Death _ 7" 19(.C__.
Age Years Month • " Days Birthplace '
Cause of Death _ /
Certificate was signed by ,/l _ eP_ __/_:_.._.__ M.D.
Address :.�.� �--- -- .�� Ce7„. rit.:24-x. -�---���� y-
,
Place of Buri (or Removal _ _ _ �� _
(If body is to be porarily held, fit n pace later)
'Cemetery_ sc c} Date of Burial 19
(If body is to a 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 haveaccepted the same
for registration, have record d.it in m ocal Re�c�ordd with the above stated Registered l tuber, a Cl-Ain he sis thereof, HERE-
BOY GRANT A PERMIT !` � 1/37
I
C��c (N me) ddress)
the _____ � � to hold temporarily an �,d-. the body
( lertaker or pers n h ving charge of corpse.), (Inter, r: :.. e, o . herwisei ispos of (state how))
Dated 19.. ! (Signed)
This Permit is ufficient for the Removal (and Interment or Cremation) of a .-/ to any part of a 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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was . ---el"-- 7 19 7�
(Interment or CrEign)
-CL:t___,2 17---e.--e-st, —
(Name of Cemetery, etc.)
Section Lot No. Grave No.
(Signed) '
/`
/ (Person in Charge)
\ 1
Address '�'" � , -4
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 1
charge," and FILE PERMIT WITHIN THREE (3) DAYS'.
with the Registrar of District in which cemetery is locate .
SEXTONS, FUNERAL DIRECTORS and UND
TAKERS violating the law relative to the return of permi
are liable to a penalty of NOT LESS THAN FIVE DO
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.
I)