DesJardins, Cathern NEW YORK STATE DEPARTMENT OF HEALTH
y OFFICIAL BURIAL (OR REMOVAL)IISF' 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.
Registered No. S
.S�Dist. No. b ounty w. Town, Villageo City
If city, give street address)
Name of deceased . • -� ✓ Veteran
(If Z�' veteran, give give name of War)
`��� Single, married,widowed 'i �. !
Sex or divorced (write the word) Date of Dq 19._�
Age __ j. Year Months Days Birthplace ll '
Cause of Death
Certificate was signed by -- _\ ; s M.D.
Address /74 S h
i.
Place of Burial (or Removal) .... . ..:tA.�. -a ,
(If body is to be to o arily held,)fi 1 in spa e la r � -
'Cemetery -,A ___./f I...� L/GL-<c Date of Burial A--/77 19
(If body is to be t porarily hel , fill in space later)
The CERTIFIC E 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 Loca ecord with the above stated R2ddress)
red Number, and o the basis ther of I HERE-
BY G NT ERM
/ (Na )
the S/��� to hold temporarily and the llody
(Undertaker or pe on/ avi[ charge of corps (Inter re ovether se dispose of (state how))
Dated /,c 19 // (Signed)
/ Local Ile stray .1-yrl/This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pat of th State kgubject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS o. 62) is required.
FORM VS. 61. (REV. 6/631 18A2-781
r' ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
`t OR CREMATIONS ARE MADE
Date of was
(Interment or/ CreYtiBtiOn)
s - ,.
Jvi'c_. I/ -Cam"'_—..
(Name of Cemetery, Crematorium, etc.)
' I
Section ' L ct_I- / Lot No. a Grave No.
l�l . 1
�
(Signed) \4
(Person in Charge)
Address rlj�
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.
Forrn yS-67 (rev. I 1/65)
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 13 male Age(yrs.)
(:a Arn DAa Jrirf9i ng ® Female 83
Place of Death (indicate whether city, village or town) / Date of Leath Cause of Death
T' f Q y c' �•/ (�t n s l e/s 2134/79 Uremia
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
[] Yes ] No
PtrfA DAB Valhi trvvil 011A A 11 S1111117 NY
State fully the final disposition to be made of body.
to be intered
Name of place or cemetery for final disposition Date of final disposition
Luzern Cemetery, Luzerne, N.Y. L /31f79
Firm Name Reg. No. Address
Potter?Funeral SeTivice 01974 136 Warren St Glens Falls NT 12801
'Slgnatur4 Funeral Dire or a d •r er Reg. N^ Late
r 7n E, 011462 4/30/79
•
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
•
1. See Section 13.1 (formerly Chapter Xlll, 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.
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