Deane, Caroline Form VS 67.
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
Gkr See Special Administrative Regulation 1, subdivision 4, Relating to the Trans-
portation 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
Mrs._ .Caroline..G.....Shaw..Deane , who died in the* City
(City, Village, Town)
of Glens Falls , N. Y. on*. F.eer..uary...11.,...1941., Sex..r.emale....,
Color or race* white , Age*....7.<. .years, and Cause of Death*.C.er.ebr.al...h.emmorhage-
arterio-sclerosis NOW INTERRED IN Pine..Vi.ew..`v.ault
(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 isNOT_to be transported by Common Carrier_
i.nt erment
by...automobile..hears.e..for ....at.l,uzerne..Ce otery-,Luzerne.,N...Y..•iMay 10,194
(State fully the disposition to be made of body (N of pl cc or cemetery)
(Signature of undertaker)
Dated.....MaY..7tn:, 19 41. Address o?z "1"4 f--=a�� w " 1� y
License No. e -3 0 7--
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request an recommen th tPermission be granted.
(Signature of Health Officer)
Dated ,7 19 4(
L;
I Instructions to Local Registrar: Fill out (a) ransit Permit for bodies trans-
ported by Common Carrier or (b) ordinary Offical 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. When data can not be obtained write "Unknown" in spaces in-
dicated by (*).
The Disinterment blank should be filed and carefully preserved in your office.