Eastman, Eva 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.)
,f Female
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City of glens Fails Probable Sepis
Cemetery now interred f,ocation (city,town or county) is body to be transported by common.carrier?
Pine View (vault) ❑ Yes ,0 No
State fully the final disposition to be made of body.
Name of place or cemetery for final disposition Date of final disposition
S:.
Firm Name peg. No. Address
Regan & Denny 'Funeral Ser. Inc. 02883 Quaker Rd.. Glens Falls, NY 12801
(Signature o f ner Rirec r o ndertaker Reg. No. Date
_ John J. Ross J4 94 4/7/78
•
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 A
Q 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. i
Registered No. 1,-3
601 Warren Town, Village Cityof Glens Falls
Dist. No. � County or City
If city, rive street address)
Name of deceased Eva B. Eastman Veteran
(If veteran, give name of War)
Female single, married,widowed, Divorced March 4 78
Sex or divorced (write the word) Date of Death 19
Age 73 Years Months Days Birthplace -_New___York.._ .t_ate
Cause of Death Probable Sepsis
Certificate was signed by Bernardo R. Villa j.uan M.D.
Address 90 South St. ,Glens Falls, N.Y.
Place of Burial (or Removal) Removal — Town of Queensbury
(If body is to be t mporaril eld, fill_in space later)
Cemetery Pine View Rec. Vault Date of Burial March 7 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
(Unlertak r o erson hay ng charge of corpse) (Inter, remove, or otherwise .ispose of (state how))
Dated � G� 719_..7i (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of a so , to any 'art o e e (subject to local
Irii
emetery or other regulations), unless removal is by common carrier, in which case . ransit Permit ( No. 62) is required.
RM VS. 61. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
•
Date of was 11 `e./ ,19 7 "
(Interment or CaretnsSi.
(Name of Cemetery, ikr art ium, etc.)
Section ��Lot No. GrNo.
(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) DAYSI
with the Registrar of District in which cemetery is locate .
SEXTONS, FUNERAL DIRECTORS and UND
TAKERS violating the law relative to the return of permiai
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.
t