Kingsley, Howard � . S.F.No.604U-1-41-20M.21148. Washington State Department of Health (sli— /
ORIGINAL DIVISION OF VITAL STATISTICS Burial Permit No -,-._-,
BURIAL—TRANSIT PERMIT
Full name of deceased •1—$:-1.t.?.-:. 1 1 , Q -.
ed
Place of death.- - t ►Q11Jt.1� :S :-, a
ul (City) (County) l, / (State)
A Date of death .-- - , 19--4Color ��J Sex (V) Age
Cause of death -4J-L,- c -�'Y �..�w -
,4 Method of disposal _.•1n.4..eT'WA--lt0qAtu Y �.
cs (Whe r burial,cremation,transit,storage,etc.) (Cemetery rematory) / (County)` , w (S f�
a> Funeral director Address ..-}
PERMIT
rzt A certificate of death having been filed a ,,required by the laws of the State of Washington, permis-
a.c sion is hereby given to .-* holding
4.) (Embalmer,funeral director,or person acting as such)
Washington Embalmer's License No tV —1 0 to dispose of the body as above stated.
4- r
Dated at - -l. 1— �p* this I O ''day of.._ , 194-.--
(Registrar's address) �
Signatur +.t,1 4.— , A144--•111
(Regist ) Q L
CP
44 CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
F Body was „S 14.,4 on W.Q4- 14, , 194 Y..P3 in rt--�,, -TQI
iA
(St te whether cremated,buried,stored,etc.) �nj (Cem cry or crematory)
Place-.. .. .'Lfl .... - -. Signature-..W� .i0..--.�. . ........... ....
SEE OTHER SID (Sexton or person in charge)
-277
This permit must be endorsed by the Sexton (or by the Funeral Director where there is no Sexton) and returned within
10 days to the Registrar of the district in which the burial takes place.
Form VS 67.
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
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
Howard Kingsley , who died in the* City
(City, Village, Town)
of Bremerton, Washington on* February 8th -.9 Sex..Lal.e ,
Color or race* White , Age* 46 years, and Cause of Death* Lobar
Pneumonia NOW INTERRED IN Pine View Vault
(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 is NOT to be transported by Common Carrier but is to be taken by
Auto Hearse for interment at GlensFalls Cemetery
(State fully the disposition to be made of body) (Name
/Name f place r emetery)
(Signature of undertaker) ,(,(f. . �
g .�
Dated riPril 29th 1943 Address 84 "barren St,Glens Nalls,P1.Y,
License No. 1338
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request an n1-?that-Peion be granted.
(Signatu : of Health Officer) `'—
Dated.. ....': .... .. r,e:pk 9....190
'Instructions to Local Registrar: Fill out (a) Tr nsit Permit for bodies trans-
ported by Common Carrier or (b) ordinary Of fical 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 (41).
The Disinterment blank should be filed and carefully preserved in your office.