Langdon, Marion orm VS-67 (rev. 11/65)
}} NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vita! 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 Deceased !Mate Age(yrs.)
arion E.. Lan-don 0 Female
Place of Death (indicate •-'hether city, village or town) Date of Leath Cause of Death
Village of So.Glens Falls, N. Y. ?. 9, 19`7 .
Cemetery now interred location (city,town or county) is body to be transported by common carrier?
0 yes E3 No
State fully the final disposition to be made of body. - a
•
Interment
N ame of place or cemetery for final disposition Date of final disposition
ee wich Cemetery,Greenwich, N.Y. i
_I Firm N.a.ce r® a` �r°
Reg. No. Address
Regan & Denny,Inc. quaker Rd. ,Glens Falls, N.Y.
;Signature of Funeral Director or Undertrtke 4,
Reg. No. Date
��- 4/26/78 I
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter Xlii, subdivision 4) of the Sanitary Code, relating to the transportation of dead bogies
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
ISF This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Distri►`
(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.
,.
Town, Village
Dist. No. County.-Sc.,._4,7c J - or City 6 ao_i • / -,..k '/• -, f-�.4(
If ci , give street address)
Name of deceased /t l C, ; v A I , I-c-_ de,. Veteran /i,
(If veteran, give name of War)
Single, married,widowed,
Sex --r�-Yr s.,/f.- or divorced (write the word) et,: r , ,/ Date of Death 'd4-"•- ' 1f 19 7d
Age Years /-, Months Days Birthplace /.1..A.->_-.2i7r it -s>4.a
Cause of Death 1,.,.. _r , .1 c-y C c c./(. ., ,.; . r�-
Certificate was signed by De ,�,/ I L. C i a.-..,C. - C c;i- -n e✓ M.D.
Address I.?(o P)u... i 77 f s cl,, r-4.- -,, ry )4
Place of Burial (or Removal) -71e::./ ,.° A ' c , Ai/
/TJ
(If body is to be temporarily held, fill in space 14ter)
Cemetery /. n L'. �-<. /) _— (,_.A.,,u 1 Date of Burial / /2- 19 7�
(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 GR4NT A PERMIT
to °� 'J me 1 (� 4 /1'd, 6v/ ra.,- ., -y, -7/ v
(Name)
I (Address)'
the £fill e .Ja.. ( L— to hold temporaril nd l;<--_�.. the body
(Unlerta. sye or person having charge of corpsse) (Inte , , or other a dispo of (state how))
ated •
° ...?' 19, ��- (Signed) -
Local Registrar
his Per' it is sufficient for the Removal (and Interment or C e at' n) of a bod to any part of the State (subject to local
ry or other regulations), unless removal is by common carrier, ' ich case a Transit Permit (VS No. 62) is required.
61. (REV. 6/63) (6A2.130)
ENDORSEMENT OF SEXTON OR PERSON IN i'
CHARGE OF PREMISES ON WHICH INTERMENT ceme
OR CREMATIONS ARE MADE FORM V
4�
Date of 1'Y1 '�� was 7-1 *?
(Interment or Cremation)
/" r
(Name of Cemetery, C*+ N^rii/m etc.,.)___.
Section Lot No. No.
(Signed) /l/✓l
(Person in Charge)
Address 6' !�
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.
4.