Bauer, Margaret Ford-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.)
0 Female 90
Place of Death(indicate whether city, villa,,e or town) Date of Death Cause of Death
City of Glens Falls ;?rebral Hemorrhage
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
QYes 0 No
State fully the final disposition to be made of body.
•
Interment
Name of place or cemetery for final disposition Date of final,disposition
-ew Hartford, N.Y.
Firm Na.ce !Reg. No. Address
quaker Rd, ,Glens Falls, N.Y.
:Signature
6 of Funeral Director or ert.t r - Reg. No. Date
.- ----- 04794 4/25/78
•
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 Officjal 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 Disc
(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. j
Registered No. (�
5601 Warren Town, Village Cityof Glens Falls
Dist. No. County or City
If cit ive street address)
Name of deceased Margaret Ann Bauer Veteran NO
(If veteran, give name of War)
Female Single, married,widowed, Widowed Jan.14 78
Sex or divorced (write the word) Date of Death 19
Age 90 Years Months Days Birthplace New York state
Cause of Death Cerebral Hemorrhage
Certificate was signed by R,W. Homer M.D.
Address 100 John St. ,Hudson Falls,NY
Place of Burial (or Removal) Tn of Queensbury,NY
(If body is to be temporarily held, fill in space later)
Cemetery Pine View Cemetery Rec. Vault Date of Burial Jan.17 19 78
(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 ,NY
(Name) (Address)
the Undertaker to hold temporarily and Remove the body
(Unlertaker or pe on having charge of corpse.), (Inter, rem r o e wise dis se of (state how))
Dated (7C,(-7 19_-_ e (Signed)
ca
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo any part of the tate (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 / 9
(Interment or
1
-6:7; "
(Name of Cemetery-, ,
Section r Lot No. Greve No. LJ
(Signed)
(Person in Charge)
Address Ate/// /
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,,ip.
charge," and FILE PERMIT WITHIN THREE (3) DA -
with the Registrar of District in which cemetery is locae
SEXTONS, FUNERAL DIRECTORS and UNDE•-
TAKERS violating the law relative to the return of per • •
are liable to a penalty of NOT LESS THAN FIVE D• `
LARS NOR MORE THAN FIFTY DOLLARS FOR T -..
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.