Ducharme, David Form VS No.67. 9-16-30-586., (17-1827)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
L"'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. Permission for D;s ;lterment must ALWAYS be obtained whether
the Body disinterred is to be transported by Common Carrier or by other means.
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
David Gerald Due harme , who died in the * City
(City,Village,Town)
of Glens Falls on* March 8, 1937 , Sex, Male
Color or race* White , Age*1 day and Cause oaf tDeat i*hsphyxia
. �� phonsus Cemetery
Neenatorum NOW INTERRED IN siest Glens Falls
(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 be Try nsf err ed
and Interred tGlens Falls Cemetery (Bay Street )
(Signature of undertaker)-- - - - -
Dated March 23 1937 Address 21 Grove ewe: . , Glens Allis
License No89 �
APPROVAL OF HEA
Dist. No._TVS- T
I HEREBY APPROVE above Qmmend that Permission be granted.
(Si nature of Health Officer)
Dated__-- _ _ g z 19_5
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.
The Disinterment blank should be filed and carefully preserved in your office.