Jenkins, Agnes 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:
Name of Deceased CI Male Age(yrs.)
Agnes F. Jenkins ® Female 97
Place of Death (indicate whether city, village or town) Date of Death Cause of Death
Town of Fort Edward 4/3/80
Cemetery now interred Location (city, town or county) Is body to be transported by common carrier?
Pine View Rec. vault Tn of Queensbury D Yes ® No
State fully the final disposition to be made of body.
Interment
Name of place or cemetery for final disposition Date of final disposition
Ferndale Cemetery Johnstown, NY 4/19/80
Firm Name Reg. No. Address
Regan & Denny Funeral Servici 02883 Quaker Rd. Glens Falls, NY
Signature of F' rat p' ector nr Uncjerttker Reg. No. Date
�. =�y 04794 4/18/80
, P
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.
-�+� \ �•• +� 111V•• I VlM VlU4V VV1/411111G111 VI 1 IGGUUI
N. BURIAL — TRANSIT PERMIT
/'Name: First Middle Last Sex
Agnes F. Jenkins Female
Date of Death Age If Veteran of U.S.Armed Forces,War or Dates
f~ April 3, 1980 97 No
Z Place of Death: City,Town or Village Hospital, Institution or Street Address
W Town of Fort Edward, NY Fort Hudson Nursing Home
A44 Causes of Death:
U Congestive Heart Failure
W Medical Certifier: N me Title Address
A i.c card ` . Hogan, MD, 325 Main St. , Hudson Falls, N.Y.
Death Certificate Filed: City,Town or Village District No. Register o.
Town of Fort Edward, NY SThI
---•
/ Date Cemetary or Crematory Address
0 Burial:
0 Cremation:
Z Removal Date Place Removed and/or Held Address
O la and/or Hold:
E April 7, 1980 Pine View Rec. Vault Tn of Queenebury, NY
c/) Date Point of Shipment Destination
Q Transportation by
Ct. ❑ Common Carrier:
rn
A Date Cemetary Address
Disinterment:
El
Reinterment:
Permit Issued To:Name of Funeral Firm Address R • tration No.
Regan & Denny, Inc. , Quaker Rd. , Glens Falls, NY 02::3
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
E- Address: N
WPermission is her y grant to1ispose of the e d human remains described above as i C
a Date Issued ` -, t\C LC1.-7L"'
_ Re istrar of Vitalis°cs (Signature) 1 1
District No. GIL,r- ^� i;)-"` ! t .i -' di'`-
• Place `
`his permit must be completed on back by the person in charge at the place of disposition and filed with the registrar of vital statistics of the city,town or village
where disposition took place.
PUBLIC HEALTH LAW
§4145. Deaths; burial and removal permits; disposition of remains.
1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompaniedpy a burial,cremation or transit permit,as provided
in this article.
2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before
interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any
transportation company,which permit shall accompany the remains to its destination,where if within this state, it shall be delivered to the
person in charge of the place of burial or other disposition.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the
funeral director or undertaker shall (a) sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the
words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is
located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES.I certify that the remains were disposed of in accordance with the permit on the reverse side on Q V
(Date)
•
at .
(Place of disposition and address)
Section Lot No. wave No..
Signature Title