Haviland, Mary t.1 v Form 88
V (Always write with black ink) TRANSPORTATION OF CORPSE
N
Q
�tV iPLACE OF DEATH Otato of Maine
State of Maine sxax. soean of aFar,xu
County of-- Cumberland CERTIFICATE OF DEATH.
City of Portland (No. Ward)Pleasant Avr�t.: Ward) (Ifa hospital death occurred
in -
2FULL NAME Mar Jane Hay i land tution give its NAME
instead of street and
number.)
`\ Personal and Statistical Particulars Medical Certificate of Death
( 3 Sex 4 Color or Race 5 Single 16 Date of Death
it %▪ - Pella'e Tf hite Married {1t��.Q.lr P
+ W"idowed May 14/22
1� " 'aor Divorced (Month) (Day) , 191 (Year)
(Write the word) 17 I HEREBY CERTIFY, That I attended deceased
�) 0 6 Date of Birth
o April 14 1840191—
u (Month) front May4/22 191 10May l4/22191
P. (Day) (Year)
a cd
n 7 Age 82 Years )rt mos dr, that Ilast saw h "alive on May 14 191
• 8 Occupation and That death occurred,on date stated above, at 10.30 P nM.
44 U 0 Re t ired The CAUSE OF DEATH was as follows:
'-' 9 Birthplace (State or Country)
East Chester New Yo 'k
\ n 10 Name of Apoplexy 10 days
x 8 Father Alex M Lane
m 11 Birthplace
c t, Q 0 .,? Z of Father
(State or country) East Chester N. 1 •
4
°
I2 Maiden Name (Duration) yrs mos. ds.
of Mother Susan A Valentine
w 13 Birthplace Hardening of Awter le
1, k...i. t: 7i
of Mother East Chester N. Y Con!ributory t�
p (State or Country) Y. (.Secondary)
- 14-The above is true to the best of the knowledge-and belief of (Duration) yrs mos. ds.
i( H .13 (Informant) 0a t F'r L Hay i land (Signed) —1 W. ...1t `•g. , M.D.
•
f(, 19}7— (Address) +
(Address)- Portland MA
tX 15 Place where remains are to be sent Date of Shipment 18 Length of residence (for Hospitals, Institutions, Transients or
At place Recent Residents)
ace In the
Glen Falls N. Y. I May 154' 2 of death yrs mos ds State yrs rhos ds.
( Shipping Undertaker Where was disease contracted,
ltli Hay & Peabody if not at place of death?
Portland Me Former or
Address usual residence
(Firm Name)
PERMIT OF BOARD OF HEALTH OR TOWN CLERK
This Permit with above Certificate, must be presented to Initial Baggage Agent and delivered withbody at destination
Mayl5l.%w 191
Permission is hereby granted to remove for burial at Glen Falls N. Y• the body
of Mary '.bane Hay i land , 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 person who is authorized to accompany the body.
7 11611a
Health Officer or Town Clerk,
Detatch above portion at this perforation, and hand to passenger in charge,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.
Detach at this perforation,and securely attach this label to the outside case.
Rules of the State Board of Health of Maine,
for the Transportation of the Dead.
Rule 1. A copy of the original death certificate, signed by the attending physician,a permit from the town
or city clerk or local registrar,and a transit label signed by the shipping funeral director and the initial baggage
agent, printed on strong paper,supplied by the State Board of Health, shall be required for the transportation
by common carriers of the bodies of the persons who have died in this State. The death certificate shall contain
such information, if obtainable,as is required in the form of death certificate which is furnished by the depart-
ment of Vital Statistics.
The permit of the town or city clerk shall authorize the transportation of the body of the person described in
the physician's certificate. The shipping funeral director shall state on the shipping label how the body is pre-
pared and the local baggage agent shall state thereon the route and the name and address of the escort.
The physician's permit and that of the town or city clerk shall be given to the escort to be delivered with
the body at destination. The shipping label shall be securely attached to the outside case. If the body is sent
by express,the physician's certiffcate, and the permit shall be attached to the express way-bill, and delivered
with the body at the destination, and the shipping label shall be attached to the outside case.
Rule 2. The transportation of bodies dead of smallpox,plague,asiatic cholera,yellow fever, typhus fever,
diphtheria (membranous croup or diphtheretic sore throat),scarlet fever (scarlet rash or scarlatina),erysipelas,
and anthrax shall be permitted only under the following conditions: the body shall be thoroughly embalmed
with an approved dissinfectant fluid,all orifices shall be closed with absorbent cotton,the body shall be washed
with the disinfectant fluid,envelloped in a sheet saturated with the same, and placed at once in the coffin or
casket;which shall be immediatey closed,and the coffin or casket, or the outside case containing the same,
shall be metal or metal lined,and hermetically and permanently sealed.
Rule 3. The transportation of bodies dead of any diseases other than those mentioned in rule two, shall be
permitted under the following conditions:
When the destination can be reached within twenty-four hours after death,the coffin or casket shall be
enclosed in a strong outside box made of good sound lumber,not less than seven-eights of an inch thick,all joints
must be tongued and grooved,top and bottom,put on with cleats or cross pieces,all put securely together,and be
tightly closed with white lead,asphalt varnish or parrafin paint,and a rubber gasket placed on the upper edge
between the lid and box;provided,however,that caskets containing embalmed bodies may be shipped to points
in this State in tight ordinary casket boxes;and provided further that bodies addressed to the Anatomical Board
of this State may be received for shipment when prepared in such manner as the State Board of Health may
direct.
b. When the destination cannot be reached,within twenty-four hours after death, the body shall be
thoroughly embalmed,and the coffin or casket placed in a strong well-made outside shipping case,
Rule 4. No disinterred body dead from any disease or cause,shall be transported by coMiinon carrier unless
approved by the local board of health having jurisdiction at the place of disinterment,and a transit permit, and
transit label shall be required as provided in Rule 1. The disinterment and transportation of bodies dead of
diseases mentioned in Rule 2 shall not be allowed except upon special perrnisson of the health authorities at both
the place of disinterment and the point of destination. All disinterred remains for transportation shall be encased
in metal caskets or metal lined boxes,and hermetically sealed: Provided that bodies in a receiving vault when
prepared by licensed embalmers,shall not be regarded as disinterred bodies until after the expiration of thirty
days.
Rule 5. The outside case may be obmitted in all instances when the body is transported in a hearse or a
funeral director's wagon.
Rule 6. Every outside case shall have at least four handles,and when over five feet six inches in length
shall have six handles.
Rule 7. An approved disinfectant fluid shall contain not less than five percent of formaldehyde gas. The
term"embalming,"as implied in these rules shall require the injection by a licensed embalmer,of not less than
ten percent of the body weight for bodies of persons dead of diseases under Rule 2,injected arterially in addition
to cavity injection;and not less than six percent of the body weight injected arterially in all other cases in addi-
tion to cavity injection,and ten hours shall elapse between the time of embalming and the shipment of the body.
Rule 8. The attached form of death certificate,town or city clerk permit, and label as described herein,
with these rules printed thereon, shall be used in this State for the shipment of bodies as herein provided.
Made at a meeting of the State Board of Health, July 13, 1915.
- -Approved by the�overno"r and Couricil;j`uly-28; 1tho.
The penalty section of the law provides that any person who shall violate any rule or regulation of the state
board of health for the,preparation,embalming,shipping or burial of any dead human body shall be guilty of a
misdemeanor,and upon conviction thereof shall be punished by a fine of not less than ten dollars nor more than
fifty dollars,or imprisonment in the county jail not less than ten days nor more than sixty days, and it shall be
the duty of the county attorney of the county in which violation occurs to prosecute all such'persons.
tel