Robertson, Marion •
Form VS No.67. 9.16-304000 (17•1$!?)
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
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
Marion $t Robertson , who died in the •
(city.village. )
of Glens..Fella. on•-..Eeb...26.,-.1.93E ., -
Color or race* white , Ages 82 years, and Cause of Death•
hypernerpl zoma - left NOW INTERRED IN Pine View Cemetery, V It
(a) The body is to be TRANSPORTED BY COMMON CARRIER for burial
at Oakwood Cemetery, Troy,, N Y
(Stato(oily the disposition to be made of body) (Name of plate a cemetery)
(b) The body is NOT to be transported by Common Carrier but is to be
at
(State tally the diepaition to be made of body) (Name of place or cemetery)
(Signature of undertaker) 1/.&wa4s f
Dated May 10 19 38 Address.. W ,'t ��_ Pte9. a;.
License No / 3 3 F
APPROVAL OF HEALTH 0
Dist. No
I HEREBY APPROVE above Request an e t ermisiri, gr ted.
(Signature of Health Officer) . .... ...
DD t `_
Dated f� l ig. d. --
("Instructions to Local Registrar: Fill out ( 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.