Lambert, Rene 4,,_
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 re ®--Male Age(yrs.)
/�1Z.y't�_ P,. e2-__r�...� .�,. ❑ Female
56.
Place o Death (i icate whether city, village or to'vn) Date of Death 'Cause of Death
_ /az/-2,4
Ce .etery now 'nterred ��p't Loo�ccaation (city,town or county) Is body to be transported by common carrier'
e, -7--2-ec-L/�Ce-,it2.e �-C 'eL -c- —v_ / ._j 0 Yes ANo
state ful the final disposition to be made of body. LI /'[
1-7.^-- --• ---Y1--,- .,_%, ,,,‘,- ,1-"24-
Nare of place or cemeteW for final dispo Lion Date of final ispositlon
c.c-?- 4/c���s,-r ?c-7-v .-//<`f6)
Zaroile Reg. No. Address
-M,..--/-11-,--- V. A.4.---,----0:4---, ,„1.--C C.;-,'L?9 2 Z 7e-44l-PI,d-,-'-7- 7 -fe:-/e ri,,'"_
'iSignature of,.F IDirector or UndertRk r Reg. No. Date V
fr7
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 Offic,sal 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
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr 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.
-go 7—
Town, Villa
.Registered No.
..._,,,,.......„.— „1/4..Lia
Dist. No.0 /1..)s-- County •-2/ or City ag, 6,,,_ -2.,,,,,,,e,—;.i. ,..9,4,,, -74-44 P.i....<„,
(If city, give stred address)
Name of deceased elle— ..• 4.9r0-7,--4.A1-- Veteran al a-) /
(If veteran, give name of War)
Single, married, widowed, '
Sex ICLi--( or divorced (write the word) .j.i...0-44---e,"-- L. Date of Death 19 •TY-=•1--
Age 6 Years 1VloWhs Days Birthplace
Cilti.j.t.,e4:,_ ltititA -r,-4-...—
Cause of Death ,
Certificate was signed by e • ---,01...„..,..„. ji.. . M.D.
Address ? :i---X ry.ii i --- -.--- "74 ,. A - --- --.,• /.....,:rei/
Place of Burial (or Removal) .e.i„ s ,.._. , 0...„,„ r_ . Qi4447...a.4..,, r Akq -(If
—
(If body is to be temporaripeld.JJI,ILn space It.sr)
Cemetery K-,-.4-1---A-Le-1-Ve, ,. i? -,- ' Date of Burial /A/A 1/ 19 7 Y
(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 registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT ,
21reys.„6144
to .g-. 0,4.,
n 1,_,._,,, _.,...ra m 0 , TA dress)
the n), to hold temporarily and ,4,G.4..."cr -4 -- 2P-4(,,,--e.1- the body
(U ertaker of p son having charge of corpse) (knter., remove, or(jt/bAirwise dispose.of (state how))
Dated ,./.,A/.2 1V9 (Signed) C:-.1.4.Mt :7) ( •••••fk.:y...a:rt-es4e.-4„,_
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a 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) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address 35 Broad St. , Glens Falls, NY
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 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.