Deeb, George Form VS"d'IV(rev. 11/65)
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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:
NB me o/f,r��t,eceased sr- o EaMale Age(yrs.)
T L7 f" t -> - ❑ Female ? "
Place f De th (i,,,((dicate whether c' liege or town) Date of Leath Caus y D'ath
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- -/),11 7 K 1 ,, tvi,1 ,-)44,--/ f.:71,$,-/-<-
Calmetery now interred Lion (city, town or count ) Is body to be transported by common carrier?
1 �"h e iii LAW C�' !.'.teal, t 3' t fi � J f? 4,` ` _ ,� ✓-1 0 Yes f No
State fully the final disposition to be made of body. �*
l ; l in I-ert-
Natne pf place or cemetery for final disposition Date of fi 1 dia oai on
s iz . f r ; Ce ,� 'r j 5 ek$ i l' N7 �% /F�
IP
Fir Na y . Reg. No. Address f� �, / r //
'$gnature of funeral Aire or! t Und ` Reg. No. Date /j `
'.let. _ 7 -z ' f it 1/712,--
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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
ILA This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration liiistrict
(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. f/
, Registered No. /4-_.�_____J
Town, Viii
Dist. No. U )county_-_tzti___ Itir .- city f •
If cit , ive.stree add e
Name of deceased. . .. .- _-_ _. ? Veteran
(If veteran, give name of War)
Single,married,widowed, �, 7 �,'
Sex92,012-- or divorced (write the word nl(l�� Date of Death _- 'mot‘ 19.EAge � (-cap o s s rthplace 27. y
Cause of Death -- . .
Certificate was signe _ _,-- < M.D.
Addre {r-A..--- --/
Place of Buria emova ) ___ - _ . ,(,(e-e
(If body is to be em o rily held, i 1 in ace later
'Cemetery ____ ___ _ .,_. ._� _____ __) _ Date of Burial-__t -_c ..2 19
74)
(If body is to be emporarily held, ill 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 reg' ion, have r rded it in my Local Record with the above ated Registere umber, and on the basis thereof I HERE-
BY ER " i--a-1Z-- thAdy14Y--- e C/ Ca2
-
to -
(Name) (Address)
the o hold temporarily and the /ody
( nlerta or pers n having charge of corpse) (I ern or oth i 'spose of (state how))
Dated ; '7 19 2. (Signed)
ca R
This Permit is sufficient for the Removal (and Interment or Cremation) a body to any pa of the State (subject tocemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is require
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 l.-c" .2Q 19 If'
(Interment or Cremation)
(Name of Cemetery,
'46—
Section17e2 Lot No. Gra o. 42
(Signed.._. 1 L-1 .�1t7 /
(Person in Charge)
Address j !?�' �e•
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above dat .
If no person is in charge, the FUNERAL DIRECTO
UNDERTAKER MUST SIGN ABOVE STATEME
write across the face of the Permit the words "No person '
charge," and FILE PERMIT WITHIN THREE (3) D
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UND 4.,-
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.
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