Dunn, Josephine ti c STATE DEPARTMENT OF HEALTH
e Bureau of Vital Statistics
z Richmond, Virginia
w •
A BURIAL—REMOVAL—TRANSIT PERMIT
0 E-■ Full name of dec
A z Place of death ?d/•5 'j(.! / ,{ 1�.i...
Date of Death 7'YL „�p (City) / (County) (State)
U 11. i, 1) �o Color W Ser :f' Age' ry 7 /` I
�y+ p; Method of disposal Ghee-t�.4- ? ' ,iu 4a-�ep ` • f •
w ' j (Whe er burial, cremation, transportation, storage, etc.) (Cemetery or Crematory)
M City dr — Q )'t t vt! p t��i
4 County State
E"t A certificate of death having been filed as required by the laws of this State,permission is hereby given
0 0 to 7 ..Laddress o' Z 4,3— VI/-(-Zrz.9 ' t - d—/k.-
t.) (Fune I rector or person acting as such)
w 4 to dispose of body of said deceased as above stated.
rn C Dated at 1000 No. f dIsao St1 Arlington,Va. this 15///) n y of `7 —' 19 4/4
�, ( egistrar's a dress) // ���.t� J
Registration District No. Signature ,�/\ t,
F (Registrar) •
a CEMETERY OR �WCRRE/MATO'RYY AUTHOR ITY SHALL FILL OUT SPACE BELOW
OW on 2-Q., Body was �J'WlN'tY es(/ WA 19 Le 6 i J '
th VI (State whether cremated, buried,q stored, etc.) Ceme% teprtorY Crema
E.
Place -&-(A ii pi.4, , /fi /� Signature o
/'_/' (Sexton or person in chareel
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 nR-EQUEST PERMISSION TO DISINTER the dead body of
do--4 . geo—et _ , who died in the*
(City, Villag , Town)
of K... .. .. . .. ... . . on* C 6 /I SSG , Sex.. 114,- ,
Color or race* , Age* } , and Cause of Death*
NOW INTERRED IN..�..4-rA-e-v--mow
(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
- `a `tea.�f - .. !01.
tate fully the disposition to be made of body) (Name of p cc or cemetery)
(Signature of undertaker)
Dated 711a...-.4c,� r 19����. Address �f.
License No. 7 2 3?
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request and recommend that Permission be granted.
(Signature of Health Officer)
Dated a-4„, ..5 19.OL..
(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.