Cole, Charles (2) Form PS No.V. & ).25$)00 (21-1315)
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. 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
C.1zaxles..E...Aole , who died in the * n;.t.- Tamil
of Glens Balls on * January 91 1938 , Sex Male
Color or race *.. :kbi.te , Age * 76..-.years, and Cause of_Deatl�*Merenterio
thrombosis , lobar pneulonia Pine iew Cemetery
e. _ NOW INTERRED IN...?Aee.i.Qing..Yault.
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
at....
(sots folly the disposition to be made of body) (Name of puce or cemetery)
(b) The body is NOT to be transported by Common Carrier but is to be
Interment at Lucerne Cemetery 10uzexnes.. I ev.
Mete filly the dlpoeitios to be made of body) / (Name a/W�oe ar )
(Signature of undertaker)r�4""-" ' G jt .
Dated April 11, 1938 19 Address. 221 Glen Streets Glens r'alls,
License number 5302
APPROVAL OF HEALTH OFFICER
Dist. No
I HEREBY APPROVE above Request d r e t P 'on be granted.
(Si ture of Health Officer) _... . .. •.. _ ....
Dated.. . . , ...a/. 9
g_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.