Breault, Bert NEW YORK STATE DEPARTMENT OF HEALTH
0 .
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itSF This permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Prl *stration District
(Town, Village, or City) in which the death occurred after the FILING and acceptance of a CORREC Igfbfr TE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Regi,,eredApe ibto,
Town, Village
Dist. No. 2700 County Monroe or City Gree:,,,-'
If eity, give St - —• ess)
r r
Name of deceased Bert D. Breault j,
iit Veteran s-,...re . . „R.-4,44f vetera , ' - "nd.1,L
e m of*ar)
Single, married,widowed, ...,.., ....,
sex male or divorced (write the word) mar-ried Date of Death 2_7`24‘79 19
Age 66 Years Months Days Birthplace Vermont -,...
Cause of Death carcinoma. af stomach
Certificate was si:gned by Warren Sherman M.D.
Addres1425 Portland Ave. hochester,NY
Place of Burial (or Removal) Queensbury, -NY
(If body is to be temporarily held, fill in space later)
Cemetery Pineview Cem. Date of Burial ivla r. 1 , 19_ 79
(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 Bent on L. Anthony far -liega-n- & Denny- Fu-n-eral-- Se Glen Falls, NY
c na- -g
(Name) e
the funeral dir. ,------,
to hold temporarilycan0 int the body
(Unlertaker or person having charge of corpse) \ Al r, r mov ,, er ise dispos orte how))
Dated Feb. 26 19 .79 (Signed)
) egistrar
This Permit is sufficient for the Removal (and Interment or Cre ation) of' 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 -441 1, was —2'B4' /19 f
(Interment or 4r-emat4on)--
(Name of Cemetery, Cr¢ cuter,eTc.)
Section fr44 . Lot No. Gr No.
(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.
Form C'S-67 (rev. t t ib5)
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 Q Male Age(yrs.)
Female
Place of Death (indicate whether city, village or town) Date of Leath Cause of Death
a 1
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.
Interment
Name of place or cemetery for final disposition Date of final disposition
2n of Northur. ex 'idV
Firm N-.,ee Reg.lio. Address
-vegan & Den , inc. 02883
:Signature of Funeral dire for o Linder ker - Reg. No. Date '
�— 970
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 regisler 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.
w.