Henderer, Jacob f IN
Form VS-67 (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 Deceased Male Age(yrs.)
J ((''
Jacob b u s 'Renderer [3V
Female /
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City of Glens Falls,N.Y, :'_�/ ,„`'`) Pulmonary Hemorrhage
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier,
Pine View Rec, Vault T> of . ueensbury,: . 1, 0 Yes No
State fully the final disposition to be made of body.
Interment
Name of place or cemetery for final disposition Date of final disposition
Gr.-A . y C .;eerie ., , - _ c ,, N. I 4/17/78
Firm Name Reg. No. Address
Regan & D ny, Inc. a � = Quaker Rd. ,Glena Falls, N.Y.
'Signature of Puner 1 irect r or ertn Re No. Date ,.
Z 8d
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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
I« This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District
(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. �—N.
Registered No.
Warren Town, Village
Dist. No. .u' County or City City of Glens Falls
If city, give street address)
Name of deceased Jacob R. Renderer Veteran No
(If veteran,give name of War)
Male Single, married,widowed, Widowed Feb. 2 Sex or divorced (write the word) Date of Death 19.78
Age 65 Years Months Days Birthplace 1NTew-_Yi1rk--.Sate
Cause of Death Arterial Pulmonary Hemorrhage
Certificate was signed by Vitale H. Paganelli M.D
Address 7 Murray St. ,Glens Falls, NY
Place of Burial (or Removal) Town of Queensbury,NY
(If body is to be temporarily held ill in space later)
Cemetery Pine View Rec. Vault Date of Burial Feb. 4 1978
(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 Regan & Denny, Inc. Quaker Rd. ,Glens Falls, N.Y,
(Name) (Address)
the ." Undertaker to hold temporarily and Remove the body
(Unlertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated ;`/S' 19_79/ (Signed)
e r
This Permit is sufficient for the Removal (and Interment or Cremation) of a body t. ;�� ject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transi, P -' it (V- 'I. . •- •quired.
FORM VS. 61. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON I
iip
CHARGE OF PREMISES ON WHICH INTERMI S'1.
OR CREMATIONS ARE MADE
Date o was �- /7/19 7P
(Interment or @meet-ienr) --
(Name of Cemetery, eO eteriam, otc.)______,_ __y
)� 7T-
Section C Lot No. G . �(
(Signed)//// Al `' ��
(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 TH
FIRST OFFENSE. The law will be enforced. Local Regis- 0 t
trars are required, under penalty, to report violations thereof. "