Crowley, Mary F • VS-67 (rev. I1i65)
Jr
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.
hereby request permission to disinter the dead body of:
Name of DeceasedEl Male Age(yes.)
'-") V e
�.' ., G• Crowley YP�,v' �..�.: p in Female
Place of Death (indicate'vhether city, village or town) Date of Death Cause of Death
Village of Granville, N.Y. 2/8/7 ? -jute Myocardial In farnti on
Cemetery now interred Location (city, town or county) is body to be transported by common carrier?
0 Yes Q No
State fully the final disposition to be made of body.
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Interment
Name of place or ce:netery for final disposition Date of final disposition r•
Firm Name
Reg. No. Address
'egan & Denny, �_ 1 Main St, ,Hodson Tails, N.Y.
;signature of funeral Directpr or it a er� Reg. No. Date
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INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
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1. See Section 13.1 (formerly Chapter X/II, 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 �
EgF This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Disks._,
(Town, Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER '
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. g 4
Registered No.
5725 yWashin ton Town, Village Village of Granville
Dist. No. Count g or Cityg
If city, give street address)
Name of deceased Mary Grace Crowley Veteran no(If veteran, give name of War)
Female Single, married,widowed, ever Married 2/8/ 78
Sex or divorced (write the wort Date of Death 19
Age 81 Years Months Days Birthplace New York
Cause of Death Acute Myocardial Infarction, ASiTD
Certificate was signed by J,. H. B. Foote M,D. M.D.
Address Fa t_Ann- __New York
Place of Burial (or Removal) Town of Queensbur--y, New-..York
(If body is to be temporarily held, fill in space later)
Cemetery Pine View Rec . Vault Date of Burial 2/10/78 19
(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 . , 51 MAin Sl . , Hudson Falls , N.Y. 12839
(Name) (Address)
the Thomas___R R. Cq_ ime to hold temporarily and Removal the body
(Unlertaker or person having charge o corpse) (Inter, remove, or otherwise dispose of•(state bow))
Dated 2/-9/7.8 19 (Signed) - .,
Local Registrar
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) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was 19
(Interment or dinemaiieii}---
(Name of Cemetery, C e c.
47
Section Lot No. GraviWi.
(Sig
ned)
)
(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.