Whipple, Allen (Always write with black ink) TRANSPORTATION OF CORPSE 11.4_18. Form 36. V.S.30M
1 PLACE OF DEATH COMMONWEALTH OF VIRGINIA
State of Virginia, STATE BOARD OF HEALTH
W BUREAU OF VITAL STATISTICS
I County of pL�� �' CERTIFICATE OF DEATH red in ahhospit occur
-
I or institution give
!L City of Ct--"^'�� � its NAME instead
(No.--. _. Sty Ward) of street a n d
>" 2 FULL NAME ... f�.
0. I
O PERSONAL AND STATISTICAL PARTICULARS t.
MEDICAL CERTIFICATE OF DEATH
Uw 3 Sex 4 Color or Race 5 Single, Married, 16 Date of Death
U 0IL ^' Widowedc-d (month, dayand year) "1 , 1931 P
�4 (wri he•.. r )
< 0 5a If Married, Widowed, or Divorced 17 I HEREBY CERTIFY, That I attended deceased
X w Husband of
4J U (or) Wife of from , 19 to , 19
ZQ.l 6 Date of Birth (month, day,an year) that I last saw h aliv , 19 ,
< n '• Y
{A a' / If Lei th� and that death occurred, on date sta above, at/o art.
1- 7 Age Years Months Days 1 daes>a .
W < ( _ The CAUSE OF �LATI was as follows:
Q W 8 Occupation of Deceased a f r �
•
U J (a) Trade, profession or
- - particular kind of work
F- (b) General nature of industry,
business, or establishment in
CL 1W., which employed (or employer) (duration) yrs mos ds.
✓ U (c) Name of employer CONTRIBUTORY
U) Li. 9 Birthplace .1/4-�`—jli_ I __ (Secondary)
(city or town) / J `�- (duration) yrs mos. ds.
I- Ix (State or country) s! 18 Where was disease contraet a-
z W 10 Name of Father .--� �� r s if not at place of death?
O 0 .$ Qt ws�'/% r Did an operation precede death? Date of
J 11 Birthplace of Father
Z < Was there an autopsy?-
co
(city or town)
F, U z What test confirm aJ7nysis? •
W (State or country) , 9
< � W 12 Maiden name of Mother (Signed) r_(.: "� , � TI- ,M.,D
ct a C it/.-C_-u-, (;_ , 19 (Address) 1_ ._ F _
0 13 Birthplace of Mother
*State the Disease Causing Death, or in deaths from Vio-
Z (city or town) lent Causes, state (1) Means and Nature of Injury, and (2)
(State or country)
'3 l..cMl whether Accidental, Suicidal, or Homicidal.
(il n 19 Pl a of Burial, Cremation, or Removal Date of Burial
I 14 Informant r • !� ' d/ L
i- s -L ./it,- 2 r 19 z o
(Address) ` r /Ui71 ,4• /! j� _. n
20 Undertaker (-
15 Filed , 19 •�
Registrar Address .t a----a' �'�'r "--
a
PERMIT OF BOARD OF HEALTH OR REGISTRAR
This Permit with above Certificate must be presented to Initial Baggage Agent and delivered with body at destination.
--
y ---..c:---,,, _. , 19
eetPermission is hereby granted to remove for burial at �� �--� " ��— s ,the body
of , above described, if prepared in accordance with the laws of this State,
printed on the back of this permit. If contagious or communicable, state name of erso4 who,is authoriad;to accompany
the b'dy.
i �, •
Health Officer or R'egistrar.
' -r
Detach above portion at this perforation and hand to passenger in char to be delivered to the undertaker at
destination. If burial is made in this State the sexton or other person superintending must send this permit and
certificate to the State Board of Health in ten days, unless burial is made in city or town where death certificates are
narmannntly filagi
Virginia Law For The Transportation of a Corpse
RULE 1. Regulations Regarding the Transporta- ets containing embalmed bodies may be shipped to
tion of the Dead.—A copy of the original death cer- points in this State in tight ordinary casket boxes;
tificate on the standard certificate of death form, and provided, further, that bodies addressed to the
signed by attending physician, permit of local board Anatomical Board of this State may be received for
of health or registrar, and a transit label signed by shipment when prepared in such manner as the
the shipping funeral director, and initial baggage State board of health may direct.
agent, printed on strong white paper, supplied B. When the destination cannot be reached within
through the State department of health by the pub-4 twenty-four hours after death, the body shall be
lie printer, shall be required for the transportation thoroughly embalmed, and the coffin or casket placed
by common carriers of bodies of persons dying in in a strong, well-made outside shipping case.
this State. The death certificate shall contain such RULE 4. No disinterred body, dead from any dis-
information as is required in the standard form of ease or cause, shall be transported by common car-
death certificate, if obtainable. The health officer's riers, unless approved by health authorities having
or registrar's permit shall authorize the transporta- jurisdiction at the place of disinterment, and a tran-
tion of the body of the person described in the phy- sit permit and transit label shall be required, as
sician's certificate. The shipping funeral director provided in Rule 1. The disinterment and trans-
ortat
shall state on the Rule
shipping label how the body is pre- ion of bodies dead of diseases mentioned in
pared, and the local baggage agent shall state there son of the Rule 2 shalhealthl authortities
thaoowed except upon permis-
orities at both places of dis-
on the route, name and address of escort. interment and the point of destination. All disin-
The physician's and health officer's or registrar's $ terred remains for transportation shall be incased
permit shall be given the escort, to be delivered with in metal casket or metal lined boxes and hermetic-
the body at destination. The shipping label shall be ally sealed; provided, that bodies in a receiving
securely attached to the outside case. If the body vault when prepared by licensed embalmer shall not
is sent by express, the physician's certificate and the be regarded as disinterred bodies after the expira-
permit shall be attached to the express waybill and tion of thirty days.
delivered with the body at the destination, and the RULE 5. Theo side easy ma z_be_ i in all _
-- MI ^iii i e s isF l be attac ecT to the outside case:
pp g instances when the body is transported in hearse
RULE 2. The transportation of bodies dead Atof or funeral director's wagon.
smallpox, plague, Asiatic cholera, yellow fever, RULE 6. Every outside case shall bear at least
typhus fever, diphtheria (membranous croup or four handles, and when over five feet six inches in
diphtheretic sore throat), scarlet fever (scarlet rash length shall bear six handles.
or scarlatina), erysipelas, anthrax and leprosy shall RULE 7. An approved disinfectant fluid shall
be permitted only under the following conditions: contain not less than five per cent. of formaldehyde
The body shall be thoroughly embalmed with an ap- gas; the term embalming as employed in these rules
proved disinfectant fluid, all orifices shall be closed shall require the injection by a licensed embalmer
with absorbent cotton, the body shall be washed with of not less than ten per cent. of the body weight for
the disinfectant fluid, enveloped in a sheet saturated bodies of persons dead of diseases in Rule 2, in-
with the same, and placed at once in the coffin or jected arterially, in addition to cavity injection;
casket, which shall be immediately closed, and the not less than six per cent. of the body weight in-
coffin or casket, or the outside case containing the jected arterially in all other cases, in addition to
same, shall be metal or metal lined, and hermetically cavity injection, and ten hours shall elapse between
and permanently sealed. the time of embalming and the shipment of the body.
RULE 3. The transportation of bodies dead of RULE 8. The attached form of death certificate,
any disease other than those mentioned in Rule 2 health officer's or registrar's permit, and label as
shall be permitted under the following conditions: described herein, with these rules printed thereon,
A. When the destination can be reached within shall be used in this State for the shipment of bodies
twenty-four hours after death, the coffin or casket as herein provided.
shall be enclosed in a strong outside box made of RULE 9. Any violation of this act shall be deemed
good sound lumber, not less than seven-eighths of a misdemeanor and punishable by a fine of not less
an inch thick, all joints must be tongued and than ten nor more than twenty-five dollars for the
grooved, top and bottom, put on with cleats or cross first offense, and a fine of not less than twenty-five
pieces, all put securely together, and be tightly closed dollars nor more than fifty dollars, or imprisoned
with white lead, asphalt varnish or paraffin paint, not exceeding thirty days, or both fined and im-
and a rubber gasket placed on the upper edge be- prisoned, in the discretion of the court, for each
tween the lid and box; provided, however, that cask- additional offense.