O'Brien, John INIG•• 1 Vl f, VIGl IG ✓G1.JCl 1 LI 1 IG 1 It VI I I f1111
r BURIAL — TRANSIT PERMIT
/"Name: First Middle Last Sex
John J. O'Brien Male
Date of Death April 9, 1980 Age 62 If Veteran of U.S.Armed Forces,War or Dates ww II
F-
z Place of Death: City,Town or Village Hospital, Institution or Street Address
w City of Glens Falls Glens Falls Hospital
A w Causes of Death:
Myocardial Infarction
Medical Certifier: Name Title Address
A
James F. Hindson, MD, 90 South St. ,Glens Falls, N.Y.
Death Certificate Filed:City,Town or Village District No. Register No.
City of Glens Falls 5601 /Jr) •
Date Cemetary or Crematory Address
Burial:
Cremation:
Z Removal Date Place Removed and/or Held Address
o p and/or Hold:H April 14, 1980 Pine View Rec. Vault Tn of Queensbury
v4) Date Point of Shipment Destination
p Transportation by
a Li Common Carrier:
rn
A Date Cemetary Address
Disinterment:
❑ Reinterment:
PermitIegano: a of Fuyra irm ! Quaker Rd. , Glens Falls,NY Registration No.
Senn Funeral Home Inc. 3
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
H Address:
Permission is here ante io dispose of the dead human remains described above as indicated„ �' >
a Date Issued • Z: ,) 2'� \ cam' ( .��/
/
/ Registrar of Vl'aT Statistics ( i oture)
District No. ,5 60
,
Place / '
/- r•i�— , l_L✓
This permit must be completed on back by the person in charge at the place of dispositiorrand with the registrar of vital statistics of tlje city town or village
where disposition took place. G
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.j
I certify that the remains were disposed of in accordance with the permit on the reverse side on l`� f
(Date)
at V C � ��-�2 � l--14/--w
(Plate of disposition and address)
Section Lot No. v Grave
�-( � ��
Signature /Z� N Title
Y
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 Male Age(yrs.)
John J. O'Brien . Female 62
Place of Death (indicate .ohether city, village or town) Date of Death Cause of Death
City of Glens Falls , 4/9/80 Myocardial Infarction
Cemetery now interred Location (city,town or county) Is body to be transported by common carrier?
Pine View Rec. Vault Tn of Queensbury,NY ❑ Yes W No
State fully the final disposition to be made of body.
Interment
Neale of place or cemetery for final disposition Date of final disposition
Calvary Cemetery, Canandaigua, N.Y. May 2, 1980
Firm Name Reg. No. Address
Regan & Denny,-Inc. 02883 Quaker Rd. ,Glens Falls, N.Y.
---`Signettae of Funeral Director 9r un rt iker �' ) /- Reg. No. Date
�ti___ yr: 04794 May 1 , 1980
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.