Andrus, Forrest VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
/Name: First Middle Last Sex
Forrest William Andrus Male
Date of Death A e If Veteran of U.S.Armed Forces,War or Dates
E., Feb. 11, 1985 S 7 Yes 1^JW 11
Z Place of Death: City,Town or Village Hospital, Institution or Street Address
w City of Glens Falls Glens Falls Hospital
AILI Causes of Death:
U Acute Coronary Occlusion
AMcHi Certifier.;
,�arry1ea , t. Glens Falls, v, ddress
Death Certificate Filed:City,Town or Village District No. Register No.
City of Glens Falls Burial: 5601
Date Cemetery or Crematory Address
❑ Cremation: Feb. 15, 1985 Pineview Cemetery, Twn Queensbury, NY
Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
F-
tn Date Point of Shipment Destination
p Transportation by
CI. ❑ Common Carrier:
0
ADate Cemetery Address
Disinterment:
CI
Reinterment.
Permit Issued To:Name of Funeral Firm his ation No.
Carleton Funeral Home, Inc . , Main utres. ,s Hudson Falls, N .Y. 0S r%
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
E. Address:
c4Permission is hereby g anted to dispo of the dead human remains described above as indicated
a. Date Issued ���'3 0� 'ems '" C �
111 Registrar of Vit t tistics (Si tune) -
District No. -i � ' ! /
D
/ Place
This 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 accompanied py 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 Z — / 5-- 9).
(Date)
at F J'l.) y f r (A) CP w PyC' fc /Q 1 c c' vo C ,o I.
(Place of dispositon and address)
Section 0 k C u.1 V I Lot No. _ ' 19 Grave No.
Signature 0--(9. 1-12A-7 --IV /1�-24". Title —j-
Andrus
Lot No. 56 A
Address �n3 Ao,- 159, (liens Falls. N.V. 12801 Section No.
Owner Patricia Andrus Plot
Mohawk
A'. X �' -1 ti_<
Date 2/15/85
ox 67 Superficial ft. @
Location Rounded North by 1'yers, South by Vacant, vast by Vacant P cordon, T,Test by Tlacan+.
Corner Posts
Remarks
Deed No. (and changes) 1909
Payment Record --aid in Full 2/15/85
Record of Interments VAC/W
1 Forrest William Andrus r--
2/15/85
2 �C1 iClQ Ann Anc1c-us 4•at...• az, ban,11 a3
3 v
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A 7
4 C E $ N,
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5 N \ I X 5
6
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8 VgCA,/r¢ 6o„c7)a,v
Form No. 01
Anarus Forrest ina llanf
LIB
Age: 57
Cause: Acute Coronary Occlusion
Lot Owner: Datrici« Andrus
Lot # 56A Mohawk
Grave # 1
Case: Concrete
Died: 2/11/85
Interred 2/15/85
Undertaker: Carleton