Glenn, Ruth drorn 0-67 (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 Of2mjesed // • Male Age(yrs.)
1 1 ti° f 111 J\ t��(K1/ 1 emale ( 7
Place of Death(indicate whether city,village or town) Date of Death Cause of Death
,�-� �-�c.,s Cali 4/ -/7t ,)• I1 L.. r r I LC.
Cerretery now interred f/ TL.oc;ation(city,town or county) Is hoidy to be 0trransported by common carrier?
r / L / Ves No
� ` nCC . 4i•1, ! t. /� 1'�'�h rT fsc"c. th•✓- .
State fully the final disposition to be made of body. -
Name of place oorr9 cemetery for final disposition J �I Date of final disposition
,1 i .; s i (../e s er/ {it tit_' Sb 6"r Cc'/I 1' V `i/ii-1 2�
Flrtriame,
J 9 Reg. No. Address •
✓ �c viti� Steh „�_� tig741 134 fr Y✓c{ St C-lu .;�5'5 N�/
;Signature I funeral Director t U d Reg. No. Date
7.I l t. 1 r L C f' �/��G/ail`
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:
\41. For bodies to be transported by common carrier, fill out Transit Permit.
For bodies not to be transported by common carrier, fill out ordinary Official Burial (or Removal) Permit.
In each case write the word "DISINTERMENT" on the Permit.
This form should be filed and carefully preserved in your of/ice.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ICE This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Distract
(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. il
Registers No. //..12-- , "
�f `/ Town, Village
Dist. No. G� �ounty 5�'J� ._ _ or City
If city, give street address)
Name of deceased._.._._ .__, .:.______ � Veteran
(If veteran, give name of War)
Single, married,widowed,
Sex or divorced (write the word) .#6-/►��--e Date o Death 2 -"-- 3-- 19 ,
Age 6 Ye Months Days Birthplace
Cause of Death j-G�L�zY_n� �
Certificate was signed b W,/Ni/ M--K,
�� M.D.
�e_;40(-4 �G J
Address `
Place of Burial poa Removal}-_ ._..i /
(If body is to be to o arily held, fill spce later)
Cemetery r. L< Date of Burial A 19 T
(If body is to be tmporarily 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 registratl have recorded it 'n my Local Record-with the above stated Registered Number,�/ ) and on the asis thereof I HERE-
BY GRANT , - \�.�2-?���C,, / j ( .oL/}./j.�ii � j� C
t0 -_ ��/1Z F
//// ^ ��// (Nam ) (Address)
the �i/ R 2-- _ to hold temporarily and the body
(Unlertaker or rs having charge of corpse) (Inter, o , or oth ise ispose of (state how))
Dated .2..K 19...E (Signed)
Local R gistrar / A' )
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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of ` '1'l-6 was ' '' �19
(Interment or Cremation)
(Name of Cemetery, C orium, eettcc.?
Section ' ``2<I Lot No. G e No. 21"
(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.