Wiley, Fred Form S-V.S.
(Always write with black ink) TRANSPORTATION CF CORPSE
NEW JERSEY DEPARTMENT OF HEALTH—BUREAU OF VITAL STATISTICS
PLACE OF DEATH Registrar's No.
County Mercer _- ( FORMER OR USUAL RESIDENCE
Township State New Jersey County Mercer
W Trenton City , Trenton
I City or Borough or Borough
F" Name of Hospital (If outsidr, orb rough I ts,name tow-ship)
or Institution Mercer Hospital Street No. 1 A rtterbury Avenue
O (If not in hospital or institution write street number or location) (If rural give location)
Length of Stay 5 Citizen of No if so, name
in this Community yrs. mos._ days hrs. foreign country? country _
Kindly Type or Print
FULL NAME
(Surname last,first name here) Fred W. Wiley
W . SOCIAL MEDICAL CERTIFICATION
IF VETERAN, SECURITY None
Li NAME WAR NO. DATE OF DEATH November 11, 1948
o SEX COLOR OR RACE Single, Married,Widowed
4 o or Divorced (write the word) I HEREBY CERTIFY, That I attended the deceased from
X Male White Widower March 10� 1948 to November 11 1948
If married, widowed or divorced Age, if ,that I last saw h imaiive on Novemberl 48and that
Z HUSBAND OF Anna L. Frier ! living
4 J (Give full maiden name) 1 death occurred on the date stated above, at 10.35 a,.
O EL (or) WIFE OF Duration
F. BIRTH DATE OF DECEASED Immediate cause of death_- --
W e (Month,day and year) - January 14, 1866 primary muscular atroph7 I Syr
("' ` AGE Years Months j Days If Less Hrs.
o w QQcc�� rs Than Generalized Arteriosclerosis--_____
�_ 8 N 9_ i 2/ One Day Min. Due to _
b- Wolcott
h- BIRTHPLACE(City or town)
• (State or country) New York Due to14.1 - -
(,) • USUAL OCCUPATION TM�erchanta
in L Industry or business. Dry Goods : Other conditions_ _Intestinal hemorrha xsISIAN
_, (Include pregnancy within 3 months-oTdeath)
cc• ,
�, W NAME Major findings: Underline
Ia ,:_ Of operations the cause to
®
U Q BIRTHPLACE(City or town)___.- ._ . . which death
IL (State or country). New York should be
Of autopsy charged sta.
o W MAIDEN NAME Melissa
tistically.
P L BIRTHPLACE(City or town) If death were due to external causes, fill in the following:
4 IL ,o
rE 0 `E (State or country) - New York Accident, suicide, or homicide (specify)
Cr SIGNATURE OF Charles W. WileyDate of occurrence
INFORMANT
O (Address)17 Atterbury Ave., Trenton,NJ Where did injury occur?
Z PLACE OF BURIAL Pine ViewCem• (City or town) (County) (State)
Cremation or Removal DATE _ Did injury occur in or about home, on farm, in industrial place;in
I Nov. 14 19_48
lB�s Fai � i�tY
public place?
N.J.License No.
FUNERAL Poulson & anise (Specify type of place)
V H While at work? Means of injury
DIRECTOR Donald C. Lynch M.D.
(Address) 408 Bellevue Ave,Trenton- NJ signature
(M.D.or other)
RECEIVED Nov.12 I9_48 Address Trenton, N. J. 11/11/48
Local Registrar. Date signed
( PERMIT OF BOARD OF HEALTH OR REGISTRAR
This permit with above Certificate must be presented to Initial Baggage Agent and delivered with body at destination.
November 12_,. , 19 48 '
Permission is hereby granted to remove for burial at Glens Falls, New York , the body
of__ Fred W. Wiley , above described, if prepared in aces dance with the aws of this
State.
r
Health Officer or Registrar.
nataeb above portion at this perforation and hand to passenger in charge, to be delivered to the undertaker at destination.
•° ' 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
Nellie L. Smith , who died in the* City
(City, Village, Town)
of Glens Falls on* Feb. 1st, 1948 , Sex Female
Color or race* W Age* 80 years, and Cause of Death*
Myocardial. insufficiency NOW INTERRED IN Pine View Cemetery 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 bet.r.ansp.o '.ted by
motor... coach for...buri.al...in at. Calera .y C etery utland, Vt.
(State fully the disposition to be made of bod at of place or cemetery)
(Signature of undertaker) -.... ........ ...... ...
Dated March 30th, �$ / Address 3 G ..St. f. Glen.s..Fal.l.s.,. N.Y.
License No 4493
APPROVAL OF HEALTH OFFICER
Dist. No
I HEREBY APPROVE above Request and recommend that Permission be granted.
(Signature of Health Officer) " �l
APR 7 1948 HEALTH OF 10ER , Queensbury,
Dated 19 Y
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.