Chapman, Bertha Form VS No.67. 11-18-24-5000(21-2830)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
ZarSee Rule 4, Special Administrative Rules Relating to the Transportation
of Dead Bodies by Common Carriers,as printed on the back of TRANSIT LABEL,
N.B. If the disinterred body is not to be transported by a common carrier,
nevertheless this Request should be filled out and Permission for Disinterment
requested as below.
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
bertha A. .;hapman , who died in the * Town
(City.Village,Town)
of Queensbury on * Larch 9th, i.888 Sex female
Color or race * AXil_t.,9 , Age * '. years, and Cause of Death *
scarlet fever NOW INTERRED IN =;rr ' Lane Cemetery
(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
�sy mctar hearse and buried at is s i'all s Cemetery June 9th' 1927
(State fully the disposition to be made of body) (Name of place or cemetery)
(Signature of undertaker `1____
Dated u a__e__9_th 1927 Address 37 I'aplc ,_t Gl ens all s , i\i .Y.
License number/ / 9�
APPROVAL OF HEALTH OFFICER
Dist. No
I HEREBY APPROVE above Request a -recommen hat Permission be granted.
(Signature of Health Officer) �LL
Dated____,. .: .. 19 _-
Instructions to Local Registrar: Fill out (a) Transit Permit for bodies
transported by Common Carrier or (b) ordinary Official 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, writing "Unknown"
as indicated by (*) when the data cannot be obtained.