Hayden, Florence Form VS No.67. 9.1630-S000 (17.1V7)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
-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 Disinterment must ALWAYS be obtained whether
the Body disinterred is to be transported by Common Carrier or by other means.
HEREBY REQUEST PERMISSION TO DISINTER the dead bott
of
it
"`^"�
11 P , who died in the *...- ... - . . . -
of
on* 1911,.a..t 115 b Sex�cuy..
Color or rac/.e.*{..-..lWL1A,lAA,. , Age* If years, and Cause o Death*
J� ��1AJl�...1� J,,Q NOW INTERRED IN.�-.. . 1 Utak—
) The body is to be TRANSPORTED B cOMMO CARRI R for A
at... - � .t( . " "
(State fully the disposition to be made d bodY)
(Named place or carnet `))" Ai(b) The body is NOT to be transported by Common Carrier but is to se
__ ar .� _ ass
(State Martha disposition to be made d body) (Name d place or cemetery)
ignature of undertaker) ji.cazds,Ataida•-•-/•l PSI I
Dated. tie i g...J Address...71 -i k • ` '"`."a'''
License No t3-5
APPROVAL OF HEALTH OFFICER
Dist. No
I HEREBY APPROVE above Requestand eco that • • granted.
ignature of Health Officer) -•
e
Dated ,- -Pa, 193.7
ic:_- structions to Local Registrar: Fill out (a) Transit Permit for bodies
trans . • ed 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.