Kingsley, Augustus Form VS No.67. 8-20-25-5)00 (21-1315)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
Eg'See Rule 4, Special Administrative Rules Relating to the Transportation
of Dead Bodies by Common Carriers,as printed on the back of TRANSIT LABEL.
N.B. If the disinterred body is not to be transported by a common carrier,
nevertheless this Request should be filled out and Permission for Disinterment
requested as below.
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
__ _ , who died in the
!lam` ���SP• (city,Village,Town)
Of � "fir on * �� c.l L -./90 , Sex -e
Color or
race * - , Age *__ 2• years, and Cause of Death *
NOW INTERRED IN_.�--, €
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
. li,fo
(State fully the disposition to be made of body) (Name ace or cemetery)
(b) pe body is NOT to be transported by Cornon Carrier but is to b -r Q
40`re.-f at �-� �tie� h
(State fully the disposition to be made of body) (Name of place cemetery)
(Signature of undertaker #"/-
Dated/ .. 46 19 3 3-- Address2/
License number �3
APPROVAL OF HEALTH OFFICER
Dist. No V -CV 1`
I HEREBY APPROVE above Request and+fecom,Inend-that Permission be granted.
(Signature of Health Officer)
to d
--- -
Dated -•- 19 --L
Instructions to Local Registrar: Fill out (a) Transit Permit for bodies
transported by Common Carrier or (b) ordinary Official Burial (or Removal)
Permit for bodies not to be so transported, in each case writing the word
"DISINTERMENT" on the Permit. The data required concerning the decedent
may be filled in from the local register or cemetery record, writing "Unknown"
as indicated by (*) when the data can not be obtained.