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Woodbury, Ethel Form VS No 67. 1-16-33-5000 (17-4089) NEW YORK STATE DEPARTMENT OF HEALTH ALBANY UNDERTAKER ' S REQUEST TO DISINTER BODY Fe 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. IHEREBY REQUEST PERMISSION TO DISINTER the dead body of afta-4- , who died in the*. ��✓ (City, Villa e, Town) of on* l�o , Sex • Color or race* , Age* - years,and Cause of De h* NOW INTERRED IN _ l/-�- a) The body is be TRANSPORTED BY COMMON CARRIER for at VJ (State fully the disposition to be made of body) (Name of place or cemetery) (b) The body is NOT to be transported by Com on Carrier but is to be at .... .. �� - (State fully the disposition to be made o y) of place or ce tery) ( ',nature of undertaker). • Dated © Address. /(5 yr��� ` '"`� 4J License No 17L` 9.1° 410 APPROVAL OF HEALTH OFFICER Dist. No I HEREBY APPROVE above Request and r ommend that erm' sion bt,granted. (Signature of Health Officer). ec Dated y/ % 19 Fe-Instructions to Local Registrar: Fill out (a) Tra sit Permit for bodies trans- ported 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 data can not be obtained. Tho n;Q;ntprment blank should be filed and carefully preserved in your office.