Heath, Agnes , IF
Is
Form VS-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:
CName of Deceased2 ' {��J/ Male Age(yrs.) 1(Jt'
iJ"f L,e�s' iI.. 11ca-it Female `! J
x. Place of eath (indi ate 'whether city, village or town) Date f Death Cause of Death
lir krrc-r 5 ', : r< t�-1(.t� f�s/�f, W f�c .�/�y'c`STi' 'e � v��'-t IJ�C
C .etery nova interred _ j„oca w (city, town or co�ty) L Is hody tot transported by common carrier?
1II C. i 1.'ew'eessi it '�sr �L"- buy -"-0�? i'-C ,/� /J�L��� 0 Yes ] No
State fully the final disposition to be made of body. /
/ D c ) h Terr"
Nato of place or emetery for final dis ositlon Date of final d' p sitio
,F774 Reg. No. Address , ,� --
`'�4`�./(evict c"""am���. . ev ) 136 { ' -, :3 6-k4 3 tc/4 N7—_ _`_
Signal o funeral pirector ndef r - Reg. No. Date /,a
,_i 3 -_. eY're'1-- ,
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 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
a OFFICIAL BURIAL (OR REMOVAL) PERMIT
6F' 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.
No.
J Town, Village jee2istered
Dist. No. ��� " ouaty or City
If city, give street address)
Name of deceased Veteran
(If veteran, giv name of War)
Single, married,widowed, 6 /
Sex or divorced (write the word)W Date of each / q 19
Age ._ 7 Years Months _. • D ys Birthplace
Cause of"Death A, —
Certificate was signed by . .. Aetit.4
M.D.
Address `'P •
Place of Buries (or Rem val)(.. . - yam._ , ��(If body is to b: porarily d, fill s - e ater) /�) ; r1
Cemetery_. ,(, ,p ,�C�e.cJ vQ�.Lt Date of Burial / 7 19 Y Cl
(If body is to •e temporarily held, fill in space later)
The CERT FICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same ap.earing to be COMPLETE, CORRECT-AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registr in, have recorded it in my Local Rec rd with the above stated Regi eyed Number, a on the basis thereof I HERE-
BY GRA ' RMIT
torJ . ... .... .. .... .... )1"->a
(Na ,' (Address)
v
the .._ to hold temporarily an the ltody
(Unlertaker or perso having charge of corpse) Mae , ove\or otJSe vise "spose of (state how))
Dated // 193-77. (Signed) J
Local Re stray
This Permit is suffi ent for the Removal (and Interment or Cremation) of a body to any p t 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. 6,631 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of , was 19
(Interment or Cremation)
r
(Name of Cemetery, Crematorium, etc.)
Section�� �42'0 Lot No. Gr e No.
(Signed) G
(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.