Danir, Elizabeth VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
/Name: First Middle Sex
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Date of D _ . Age If eran o .S.Armed For s,War or Dates
E1-4 [p/ cS -O[S---- 67
Z Plac eath: yy,Town or Village '"Hos tal, Institution or Street Address
14
o W ofith: �W �Q r. N.�/ � Title A/+ e
i6i i to' it-d: ' , own or Village � ii nc No. egister No.
❑ Date /r r��aid-- `-�� emetery atory dress
vial: l/ r1
Cremation: "�
Z Removal Date Place Removed and/or Held Address
0 ❑ and/or Hold:
I-0
/D Date Point of Shipment Destination
Q Transportation by
I�M ❑ Common Carrier:
v)
ADate Cemetery Address
Disinterment:
0
Reinterment:
sus. To: a,+e of Funeri rr A•dre` Registration No
ame of Fu ,r Firm Making eis:•sition or to Whom Remains are hipped, 1'?P"e16 A'.ove: i
(- Address:
Permission is hereby granted to-dispose of the dead human remains described a e s ind ate
aDate Issued 6 - .� -' Q
egis rar of Vital S ics (Signature)
District No. 5'60J
Plac `
This permit must be completed on back by the person in charge at the place of dis a filed with th registrar of vit ics of thity,Tow 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 6/2tP.5
(Date)
at St. Alphonsus Cemetery, Pine St. & Luzerne Id. , Queensbury
(Place of disposition and address)
Section Spec. Sec. D Lot No. 92 Grave No. 1
Signature Q.0. CJ.(_.k' nil- ( � A/ Title Pastor