Benton, Lela Form VS No.67. 6-16-30.5tu0 1;-1527`
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..
Lela G. 3e nt on , who died in the *='own
(City,Village,Town)
of Marcy, • Y• on* .1ea.2nd,1939 ., Sex, female
r:hi to Age* 58 of Death'texact cause unknown
Color or race* , years, andCause
in
probably l:iesenteric vasculariW 443134R2D IN Pine View Cemetery
(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
?orrre T'17crre,'"
(State fully the disposition to be made of body) (Name of place emetery)
of undertaker
(Signature )
Dated April 23th 19 39 Address 221 Gler. St. ,Glens Falls
.,y
License No 53°2
•
3
APPROVAL OF HEALTH OFFiCER
Dist. No
I HEREBY APPROVE above Request an recommend tha rmis ' n granted.
(Signature of Health Officer)
Dated . Icy 19 39
Instructions to Local Registrar: Fill out (a ransit 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.
// 9-.,-
. 1.23-35-10,000 (17.5155)
Form VS No. 62.
TRANSIT PERMIT
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
, A Transit Permit and Transit Label issued by the Local Registrar of Vital Statistics must accompany each
dead body transported by a common carrier.—Regulation 1, subdivision 1.
UNDERTAKER'S tcERTIFICAT
i iierebs (IIerttfy that the accompanying dead body of_ �� —
-----••-- - •-• - �_ _ who died in the_.... V-----1` of T
d (Cillage or Town)
7 s.ingte•
0 County-of - --�'-� State of New York, on ��— 19 37 Sex15`�--`--- -.0 ' Widowed
�y Ebi..,,,.,.1f
$ Color or race _. . , Age...J.o._years onths�3-days, Birth lace` `gip`-'
o
Y p r`, .___ _ and Cause of
-riDeath..._1�-r�c-a- zc'.s- eni--' ' ,,_„, AB c .0 u-o.-< c —
j0_2 • ' has been prepared for transportation
' strictlyin accordance with Regulation b �3 � �� gu , su division as printed with this blank. Certificate was signed by
� ^"' -""-G.-�' 0" - c-d`-Q'^4-, M. D., Address_.L.. ' -,......-.__... . . Dat of shipment
19—..._; Route of shipment..__ _ ut1�.RtaL • �!t' . •L Colt._.‘ Foint of
Cshipment_...__......-�C ..._.... ; Point of destination.._ ..... _ �- >
3 (Signature of Undertaker)__!1� •
ADated__._...._..0..6......2. 19 Address � ._..._....—_._ ...._..._...._........—..__.._....—._.__....___...._
3 'Cross out words not applying.
-�a PERMIT OF LOCAL REGISTRAR
Dist. No. .._i r..',. „ _ Registered No. 2 /
Date of issuance_. --e,._. ,.1....1. .... 19_..._....
A satisfactory Certificate of Death for above decedent having been filed and recorded in my office, PERMISSION IS
HEREBY GRANTED FOR THE REMOVAL AND SHIPMENT OF THE BODY.
(Signature of a b Re strar)!., .k.P `/ne,,(d �••_. __ —••__,._,.._•...,•
Local Registrar of the._ -'t -� _V of____-771—e/---"--e- County of.. ""ti ---t'c.--t_t -at--"--
(City,Village or Town)
State of New York.
igF Only the Local Registrar (Deputy or Subregistrar) may issue a Burial, Removal or Transit Permit
Detachrhere and give part above to escort or attach to waybill if shipped by express
l
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON -4*-11
WHICH INTERMENTS OR CREMATIONS ARE MADE
Dateo£___.._....._ ..__..___..._. �.........._ was__...._._.14 - ...._ - — __19_/
(Inter:ficnt ortC ation)- —
(Signed)- ;.44-.... _ - _-- _.__._ .._._._.._._..__ _.. .__._..___._..._...._.. _ _._.._
-IL
�` ' _ !Lus I Y�
Person in charge of_. _... _.
1 (N e of emetery, Crem ri , etc.) ,1;
Person in charge must return this Permit to Registrar of jus District wi in SEVEN (7) DAYS from above date. If no person
is in charge, THE UNDERTAKER MUST SIGN ABOVE STATEMENT,write across the face of the Permit the words"No person .
in charge," and FILE PERMIT WITHIN THREE (3) DAYS with Registrar of District in which cemetery is located, ,a`
EXTRACTS FROM VITAL STATISTICS LAW i *
§ 379. -Duties of undertaker. In each case the undertaker..or person having charge of the corpse, shall file the certificate of
death with the registrar of the district in which the death occurred and obtain a burial or removal permit prior to any dispussition
of the body. * * * The undertaker shall deliver the burial permit to the person in charge of the place of burial, before interring
or otherwise disposing of the body; or shall attach the removal permit to the box containing the corpse, when shipped by any
transportation company; said permit to accompany the corpse to its destination, where if within the State of New York, it shall
be delivered to the person in charge of the place of burial.
§ 380. Duties of undertakers; interment within the state. Ii the interment, or other disposition of the body is to be made
within the state, the wording+of the burial or removal permit may be limited to a statement by the registrar, and over his signa-
ture, that a satisfactory certificate of death, having been filed with him, as required by law, permission is granted to inter, remove
or dispose otherwise of the body, stating the name, age, fix, cause of death, and other necessary details upon the form pre-
scribed by the commissioner of health.
§ 381. Interments. No person in charge of any premises on which interments or cremations are made shall inter or permit
the interment or other disposition of any body unless it is accompanied by a burial, cremation or transit permit, as herein pro-
vided. Such person shall endorse upon the permit the date of interment, or cremation over his signature, and shall return all
permits so endorsed to the registrar of his district within seven days from the date of interment or cremation. He shall keep
a record of all bodies interred or otherwise disposed of on the premises under his charge, in-each--case stating the name of each
deceased person, place of death, date of burial or disposal, and name and address of the undertaker; which record shall at all
times be open to official inspection; provided that the undertaker or person having charge of the corpse, when burying a body in
a cemetery or burial ground having no person in charge, shall sign the burial or removal permit, giving the date of burial, and
shall write across the face of the permit the words "No person in charge," and file the burial or removal permit within three
days with the registrar of the district in which the cemetery is located.
k
SEXTONS and UNDERTAKERS violating the law relative to the return of permits are liable to a penalty of NOT
LESS THAN FIVE DOLLARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be
enforced. Local Registrars are required, under penalty, to report violations thereof.