Merwin, Francis j •
4
Form VS No.67. 9-16-30-5000 (17-1827)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
l 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
Francis 0. Merwin , who died in the *
(City,Village,Town)
of Avon Park, Florida -,on* Jan. 22,. 1939 , Sex, Female
Color or race* White , Age* 80 years, and Cause of Death* Crushed in
auto accident NOWITERRED INPineview Cemetery Vault
(a) The body is to be TRANSPORTED IY COMMON CARRIER for
burial lnn Mountain Lake Cemetery
.^`
at.. _
(Statefafl►the disposition to be made of body) (Name of place or cemetery)
(b) -The body is NOT to be transported V Common Carrier but is to be
(Signature of undertaker) Ce td ,l.
Dated April 132 I 39 Address 84 Warren Street
License No. 1338
APPROVAL OF HEALT . -
Dist. No _..
I HEREBY APPROVE abov; : -e - = •• -/. granted.
(Signature of Health Officer)
Dated
17-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 44
"DISINTERMENT" on the Permit. The data required concerning the decedent 4
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 belled and carefully preserved in your office.
'''..-County Highland s STATE BOARD OF HEALTH OF FLORIDA
a N Precinct BUREAU OF YITAL STATISTICS
(Write name, not number)
° gp
r.
m or Permit No.......
a
Inc.Town Removal and Burial Permit
m T City
orAvon Park, Fla. Reg• Dist. No d
• a Full name Frances �. b erwin ; Age 80 Sex ; Color white
o s Cause of death Crushed in auto accident
0
•- .2 'm Date of death Jen 22 19 39Removal to Glen Falls/ N.Y.
E o m Via S•A.L. Funeral Director's License No 239
a.
Funeral Director Ste henson Funeral Home
Avon Perk, Fla._ Address
If the body is embalmed, the licensed embalmer is required to file an affidavit with the local registrar before burial, removal or transit
f. ',o o permit is issued.
r• m A Certificate of Death having been filed in my office in accordance with Laws of on 1 on e the removal and
m burial of the body of said deceased person as stated above. •
° -, Jan 24th 39
o o Dated 19 Local Registrar's Signature
o c
t ' Burial Permits must be a ivered by the undertaker to • -xton or other persons charge of t e burial ground or cemetery whekle burial takes place.
a c u When the body i o e shi ed to a distant point, requirin• the se ice of a common c rrier, in addi ion to the Removal Permit, the body must be accom-
N E panted by a Tra sit .bel r requir y the tate Boar.,1 al,• For f I particulars see R s and Regulations governing the tr.nsportation of dead bodies.
h o a Sexton's Signet# ... •�
Date of Inter 19c3
a -n This permit must be endorsed by the sexton a d retu d to the Local Registrar of his district within ten days. If Iris is no sexton or person in charge
of burial ground, the undertaker or person acting as such, shad sign same as sexton, giving date of interment. Write across face of permit the words, "No
person in charge," and return to Local Registrar of the district in which interment is made within ten days.
Only the Local Registrar (Deputy or Sub-registrar) may issue a Burial. Removal, or Transit Permit.