Mabb, William Form VS No.67. 9-16-30-5000 (17-1827)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
iir'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
William "C C. Ma ob , who died in the * C i t y
(City,Village,Town)
Glens FallsSex_
Color or race* white , Age* 1 years, and Cause of Death* Lobar pneumania—
Pneumo-thorax- empyema NOW }N f E.D. IN Pine ViewCemetery Vault
(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
to be mole et
, f
(Signature of undertaker) __ - _
Dated
may g2rid
Ig 39
Address 221 /len St. ,Glens FaL-s,N.Y.
____ _
License No. 4493
APPROVAL OF HEALTH OFFICER
- _
I HEREBY APPROVE above Request and rec tha ermission be granted.
(Signature of Health Officer) ` ' . eletelA
Dated___May y•, 19 39
IR-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.
The Disinterment blank should be filed and carefully preserved in your office.
Form VS. 61.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CBRTIfICATE OF
DEA' L I�j. 1N DURABLE BLACK INK.
Djst. vC � ._...:.:: RegisNo
•
Town
County.
t /��Ity (If c' giv et address)
Name f deceased.....»... .»»_.».»... ...».». .... <=�=�%�'r f ... ». w». ......_,_...».
i Single, married, w , /
hex... .Color. � ...Y»or divorced (write the word) Date of Death. 01 4 n.. 19
Age wears" /nths..._ c- ys Birthplace.. • _._ »W:...»
Cause of Death.._._ ' t..t..s .
C�cate'was signed by »..». .... _ ._.._.M.
Address 0.-e(z.... . ... ... _...._...._ »__.»»....»_....
.
Place of Burial (or Removal).. ..... S� � ._._ .... . ... _....
(If body into be temporarily held, fill in space later)
Cemetery ». _ L v.._...» t j Date of Burial ... 19.
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to , after careful examina-
tion, the 'same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAW,
I have,accepted the for regis, .no., have recorded it in my Local Record with the above stated Registered Number,
and a the of RE.Y T A PERMIT
4. '"f2 , 54l4
t e...... . .. ..» . »..»er to hold lnporaril an .... .....,.». the body.
(U parse hag:.�`ge of co .,Y (In emove, otherwise dispose f [snte how )
Dal ...»_ . 19.. . (Signed) .». ..F. . � » ...».» ...
»... ... . Localstray
This Permit is icient for the Removal (and Interment or Cremation) o %�.• Ro my part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which case a Tra•:it Permit (VS No. 62) is required.
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