Mc Neil, Etta Fum VS No.67. 3-20.3d170 (21-1315)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
Sp 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
Et McNeil who died in the " City
— ta (City.Village, )
of Glens Falls ons January 14, 1938 Sex emale
Color or race ' White , Age * 72 years, and Cause of Death •..A1MP.94rlitle
chronic cardiac dropsy resu Receiving Vault
F y R3R�ilbt£� IN. Pi•ne• lie,vEemetssy
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
at
(State fully the disposition to be made of body) (Noma of ohm or cemetery)
(b) The body is NOT to be transported by Common Carrier but is to be
InterreJ at Nort. • Eyle Cemeter
(State fully the dsposition to be made of body) i (Name of
(Signature of undertaker).... £
Dated. MANAll ALISM 19.M.. Addr•.21 Glen St Glens alls,N.Y.
License number 4493
APPROVAL OF HEALTH OFFICER
Dist. No 4.I[-...'I
I HEREBY APPROVE above Reque :•d that P .t t'.;oat) granted.
/ ��I
(Signature of Health Officer) .�-•-
a
Dated March lQt)) r9 38
1'47 Instructions to Local Registrar: Fill out a) Transit Permit for bodies
transported by Common Carrier or tb) 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.