Richards, Edith VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
/Name: First Middle Last Sex
Edith Richards female
Date of Death —Age If Veteran of U.S. Armed Forces,War or Dates
H 5/1/85 78 no
WPlace of Death: City,Town or Village Hospital, Institution or Street Address
City of Glens Falls Glens Falls Hospital
WCauses of Death:
rJ Cardiorenal Failure
AMedical Certifier: Name Title Address
A,M. Certain ID Maple St . Hudson Falls, NY 12839
Death Certificate Filed:City,Town or Village District No. Register No.
Glens Falls City Clerk::N)>
5601 �.22�
® Burial: Date Cemetery or Crematory Address
0 Cremation:
5/4/ 5 Pineview Cemetery ( ueensbury, NY
Removal Date Place Removed and/or Held Address
2 ❑ and/or Hold:
f—i
rA Date Point of Shipment Destination
Q Transportation by
p, ❑ Common Carrier:
rn
A Date Cemetery Address
Disinterment:
0
Reinterment:
Permit Issued To:Name of Funeral Firm Address Re istration No.
M.B. Kilmer Funeral Home 82 Broadway Fort Edward , NY �1328
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
f— Address:
cG Permission is here ra d to a of the dead human remains described abov Indic
W Date Issued ..- ` -"
G.
Re stray of Vital Statistics nature)
District No. -6 6e/
`his permit must be completed on back by the person in charge at the place of di t' an Ile wlih the r stray of vital stic e city,town or ill
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. l�
I certify that the remains were disposed of in accordance with the permit on the reverse side on r` e
ii (Date)
I� `
at F >v -E' 1/ 1 e ul) C3 M-e—re t v t� k \j 11-
(Place of dispositi n and address)
Section _ 1 L F' /N „ ���1 e�=. 4 of No. 2- 7 Grave No. -�
Signature 6— gnSl e )---,----1ei-r Title c A