La Voy, Georgia Form VS No.67. 8-20-25-5)00 (21-1315)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
IV,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 z' .La
oar , who died in the * '
(City,Village,Town)
of ens 1 on * rcii , Sex le ,
Color or race * t e , Age * 14 years, and Cause of Death * t r4I).tQ o c eus
placed tine ' i.e "e?peter/ vault
NOW-IN-TERRED IN:.
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
at
(State fully the disposition to be made of body) (Name of place or cemetery)
(b) The body is NOT to be transported by Common Carrier but is to betransferred
Guth :�e,is :ails sr
'�tr '-,n^r,nn , -*, c'-�t)_ � JLlt�.7.1. i: . � .
-��. .ri<,.�t at
(State fully the disposition to be made of body) (Name of place or cemetery)
ziiii efx,fze.„,tes,____c___
(Signature of undertaker)Dated -pull 25 1906 19 Address on. Falls, s` ,`T:.
License number
APPROVAL OF HEALTH OFFICER
Dist. No r f 7
I HEREBY APPROVE above Request and recommend that Permission be granted,
(Signature of Health Officer) ,44V-Ai - ceAr
- I
Dated__ 8 -- 19 -__-
ER-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.