Girard, Ida (rev. 11/65)rill
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.)
Ida A. Girard Female 74
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
City of Glens Falls 2/15/80 Cardiac arrest
Cemetery now interred Location (city, town or county) Is body to be transported by common carrier?
Pine View Rec.Vault Tn of Queensbury p Yes la No
State fully the final disposition to be made of body.
Interment —
Name of place or cemetery for final disposition Date of final disposition
Southside Cemetery, Tn of Moreau, NY 4/14/80
,Firm Nafee Reg. No. Address
Regan & Denny,Inc. 02883 Quaker Rd. ,Glens Falls, NY
'Signature of Funeral A' for or ndertq er Reg. No. Date
k 04794 4/14/80
.
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.
( *.l. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rze- 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ,_,
Registered No.
Town, Village
Dist. No.....:...,2 .:'' County Warren
or city City of Glens Falls
(If city, give street address)
Name of deceased Ida A. Girard Veteran No
(If veteran, give name of War)
Single, married, widowed
Female ,
2/15/80
Sexor divorced (write the word) Married Date of Death 19
Age 74 Years Months Days Birthplace New York State
Cause of Death Cardio—pulmonary arrest
Certificate was signed by L.J. Greenberg, M.D.
Address 416 Glen St. ,Glens Falls, N.Y.
Place of Burial (or Removal) .::own of queensbury, N.Y.
;If body is to be temporarily held, fill in space later)
2emetery Pine. Vi.ew. .Rec.. Vault Date of Burial .2/.1.9 19 80
;If body is to he 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 registra-
:ion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to Regan & DennylInc. Quaker Rd. ,Glens Falls, N.Y.
(Name) (Address)
the Undertaker to hold temporarily and remove the body
(Undertaket)or pen having charge of corpse) citi,er,, remov , or the is ispose of (state how))
Dated k.74- - ( I 19 6,, (Signed) 07-1)----
Localgistr
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of r State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No.462) is required.
FORM VS. 61. (REV. 6/63) (9A2-205)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
61.14 4a 19 �
Date of was
(Interment or room """'
(Name of Cemetery, .C,remau.r.iursr,.etc.,,).,
Section r zzt Lot Grave No.
(Person in Charge)
, Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.