Twichell, E W 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
':;I.rtn of Queens-
ev. E. . zvic'm m11 , who died in the* bury
(City, Village, Town)
of `Varr0n County on* Dee ember 28 ,19 ,i , Sex --1 1Y ,
Color or race* whit e , Age* 62 years, and Cause of Death*COronary Se11.lerosis
NOW INTERRED IN PI` e View Vault
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
inter, at Port Hill Cene eery
(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
- - at ,
(State fully the disposition to be made of body) ,(Name of place or
cemetery)
(Signature of undertaker) . ...... 0 V. P3-7.��r--�
Dated -Lay 1Etll 19 Address8`i ',Varren: St. ,Glen Fal1s,N.Y.
License No. 1338
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request a recom nd at Permission be granted.
(Signature of Health Officer) ,.t---i--- _
Dated _:1)," 7--
...... g-- h �
19 ("
_ "Inst__ tioons 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.