Merwin, Miles •
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
Lilies Tyler Lilerwin , who died in the* Vi.11.a,Te .
(City, Village, Town)
of Avon Park, Florida on* January 2.Qtii,.1.9.43., Sex Male
Color or race* ''bite , Age* 93 years, and Cause of Death*
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 inte_rr.ent at..flue..iiount.ain..Lake...C.ernet.ery
(State fully the disposition to be made of body) (Name o place emetery)
(Signature of undertaker) f I...... . .
Dated • I414Y...1St• 19 43 Address 84 '.Warren St. ,Glens Falls
License No. 1338
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request a rec mei '_erxni be granted.
at f Health lefficer)•
Dated c'? 19.1
Instructions to Local Registrar: Fill out (a) Transit 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.
BURIAL - REMOVAL -TRANSIT PERMIT
Place.of Dvth:
,i- FLORIDA STATE BOARD OF HEALTH
x County BUREAU OF VITAL STATISTICS
lil Ce
a. Precinct
i City or Town aliAdAd &AA- : 1400 NUMBER OF PERMIT /
,,..-1
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.___.ii,,,tiA,„ ,
x Name of Deceased -70-A-e-e-c, 73.1-6114.4/•-t.t...-. Age9_.3 Sex "ft __Color -r-A---)
I-:
..1
4 Date of Death ,19 i Name of Cemetery or Crematorium
>
O V011_,f-
x Removal to: City State 17,
w
ce
..., I hereby certify that I have prepared for burial or other disposition, the body of th above named deceased strictly in
< accordance with the laws of the State, of Florida and the Rules and Regulations of the State Board of Health of Florida
ij governing the •sposition of dead hum bodies.
ca
0
kl Firm Nam --g" _,-.4-4(_,f'"L° (Signa0At"t.-.,,,, ...- a , License No.
(FU RAL DIRECTOR)
0)re
- A death certificate having been filed in my office, permissiin is hereby g anted for the burial, transportation, cremation or
< placing in vault (cross out words that do not apply)(Of the body of ei above n ;.,(Ldecease .
1r (Signature) Local Registrar
<
)-• If the body is embalmed,the licensed embalmer is required to file an affidavit with the local/registrar before Burial- val-Transit Permit is issued.
to
W The Burial-Removal-Transit Permit must be delivered by the undertaker to the sexton or other person in charge of the cemetery where burial takes
ir place.This Permit must be endorsed by the sexton and delivered within ten days to the local registrar of the district in which burial takes place.If
i there is no sexton in charge of cemetery,the undertaker or person acting as such shall sign the Permit as sexton,write across the face of Permit the
D words,"No person in charge"and return Permit to local registrar.
.
,o
x Body was Ctieget,,C.cci, ...t.4,-4, ,X,es.A.i."4.41.- Jo/4,444 on ,0-4")4- 45A- 19 7_1? •
, in
(STATE WHETHER BURIED. CREMATED OR .ACED IN RECEIVING VAULT) ..ii.
Cemetery City ",,F-04' co Wage State.
a.
w "Lg.
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(Signature) 74.41... 4A4.A. aeadt.dvaimizt
. (SEXTON OR PERSON IN CHARGE)
4
5 If Body is to be Shipped, fill out th spaces below:
w
Alui _
re _
4 Shipping Station /(-A-14--.4 Gut", ,Florida, for Name of Cemetery
<
U (STATE WHETHER BURIAL OR CREMATION)
0
-I (if obtainable _... he itta2ie4.i,c 1511.44....S__ "1•9!: State
-- '- ..-. fre#v JPP
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11 Consigned to Address —.11,445 / .e., vs' X./......, /V--
i'''-' 14 of a e. 0 V61 ir i
1 I hereby certify that I permitted the shipment7 the above named deceased his day of , 19
0
ii (Signature) (-(
1.-.
(TI EXPRESS AGENT)
Z Name of Transportation Company ii el:AL_Wil, 8