La Bounty, Adele Order by Number
Form 5-V.S.
(Always write with black ink) TRANSPORTATION OF CORPSE
1 PLACE OF DEATH STATE DEPARTMENT OF HEALTH—BUREAU OF VITAL STATISTICS
W County :..,.:..:., State NEW JERSEY Registered No
= Township .i.r„ ,. or Borough
I—
City No ....;....:::......-....,....- St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number.)O
2 FULL NAME,.,..:. ,..,..+n ..i..... „
IL = 3 Residence. No -......4,‘,.-...,....... ,..+ St., Ward
0
(Usual place of abode; in institutions, homes, etc., former residence-alseuld be stated.) (If nonresident give city, town and State.)
days. How long in U. S., if of
Q Length of residence in city or town where death occurred yrs. - mos. foreign birth? yrs. mos. days.
U Q PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
I— 4 SEX 5 COLOR OR RACE 6 Single, Married, Widowed 17 DATE OF DEATH
Q• O or Divorced (write the word) _..u.cA 19�
W W __ 18/I/-HEREBY C RTIFY That I a tended deceased from
Z <o 7 If married, widowed or divorced 1 - ,.
HUSBAND OF - - r 19?a!/., to � v �' jr 19� •r
Z —I (or) WIFE OF(Give full maiden name) I st saw4h -42-1" alive o .. ^ 7'7 , 19.air,,
(j) 8 DATE OF BIRTH
`.ip and death occurred on date state above, at 6 �' m.
- I- (month, day and year) - 1 "-
Days IIf Less Hrs. The CAUSE OF DEATH was (see over)
Ill < 9 AGE Years Months
Q 0 , iThan
U- —I " 10 One Day Min. Qq q
b- iz 10 OCCUPATION OF DECEASED
1—, (a) Trade, profession or • --.c:i
it W particular kind of work a.t,.c.....:..........V.in. i
W H -(b) General nature of industry, i r... (Duration)»......»,.yrs.„„....„„mos.»„„•,„„da,
U < business or establishment in Contributory k 1 —K•m' ........».„„.... , ,
U which employed (or employer) .-.._
(c) Name of - - (Secondary)
empl-
-�
.� - ., _ _, n (Duration) yrs mos...»....„..da,
I- 11 BIRTHPLACE (City or towns.:.,.». ......,.....dd.:r...k
I— ct (State or country) y' y 19 Where was disease contracted, _
W - if not at place of death?
Z 12 NAME OF
O U FATHER . u.Y 4- ; If an operation preceded death give date
Z 1: FATHER
BIRTHPLACE OF Was there an autopsy'
—
Q 1 FATHER (city or town)......._.. What test confirmed diagnosis?
,414.,-4--‘44-4 0 Z (State or country) V�i_ ..id-a
r• _ W .... „..................1f.
Q cc 14 MAIDEN NAME (Signed)
1 0 < OF MOTHER "31:. , (Address) r................»»» 7 . i .,,
O a.
13(a) BIRTHPLACE OF - 20 PLACE OF BURIAL , ,
lLt. MOTHER (city or town).. a......„..„............ Cremation or Removal - - K -
Z (State or country) • _ - _ _.-._ _ _,,
- 15 SIGNATURE OF Date of Burial Ly...friartAcer
IAINFORMANT ...u...» ....... ,x
2 (Address) _, _,, ` , 19 ..
U.TI— 16 Address I N License
11 /J�/� Number
Received �r 1911 �../.y �• ILL. ........
/ l ,- LOCAALREGISTRAR. •-
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.
14 w „ 19
Permission is hereby granted to remove for burial at - - ,,,_, the body
of ., , above described, if prepared in accordane_e withw the.las Qf this State,
printed on the back of this permit. (72115-4—�'7�-- -
7211,
Health#4v-,,X.
Or Registrar.
Detach above portion at this perforation and hand to passenger in charge, to be delivered to the undertaker at destination.
Rules regulating the transportation of dead human bodies issued by the Department of Health of the State of New Jersey.
1. The transportation of bodies dead of small-pox, Asiatic cholera, yellow fever, typhus fever and bubonic plague is
forbidden except a license therefor is first obtained from the State Department of Health or from an inspector or officer of
said department,and no license for the transportation of bodies dead of said diseases will be issued until it is shown that
said bodies have been prepared in accordance with the written requirements which shall in each case be specified and
made a part of said license.
When the dead body is not to remain unburied longer than seventy-two hours-
2. The bodies of human beings dead of any cause whatsoever other than the diseases in rule number one shall not be
transported by any common carrier unless said bodies shall first have been treated as follows:
(a) Remove all garments from the dead body and apply to the surface a solution of bichloride of mercury prepared as
follows: One part each of bichloride of mercury and muriate of ammonia to 1,000 parts of water.
(b) Fill all openings with cotton wool which has first been saturated with the mercurial solution and allowed to dry
The cotton used should be dry and be firmly packed.
(c) The body should be placed in a coffin or casket, and should rest upon a layer of sawdust or other absorbent material
not less than two inches in thickness. After the body has been placed in the coffin, the coffin should be securely closed.
(d) The'coffin or casket containing the dead body should be placed in an outer box, strongly made of seven-eighths
boards.
When the dead body is to remain unburied longer than seventy-two hours, and in all cases of diphtheria, membranous croup,
scarlet fever, chicken-pox, measles and erysipelas
3. After being prepared as required by rule 2, the dead body, contained in the coffin or casket, should be placed in a
substantial metal-lined box, and said metal-lining should be made air-tight by soldering all the joints and seams.*
4. In case of dangerous communicable diseases the body should not be accompanied by persons or articles which have
been exposed to the infection of the disease unless a certificate has been issued by the local board of health,or its authorized
officer, showing that said persons or articles have been rendered free from infection.
5. Every dead body transported out of the State must be accompanied by a transit permit showing name of deceased,
date of death, age, place of death,cause of death and the point to which the body has been transported, and also the name
of the person authorized to accompany the body, if any person is so authorized. Tti..e transit permit shall be securely
attached to the outside of the coffin-box and shall not be mutilated in the process of being a> �b
6. No disinterred body shall be offered for transportation to any common carrier uuiess the d has been
authorized in writing by the local board of health, nor unless written consent for such transportation shay have been
obtained from the health authorities of the locality to which the said disinterred body is to be consigned. All lisinterred
bodies shall be enclosed in an air-tight metal-lined box and all joints and seams in said metal-lining shall be soldered.
Bodies placed in receiving vaults shall be treated in the same manner as bodies buried.
7. Dead human bodies which are prepared in New Jersey for transportation within or across the State by common
carrier,and which are offered for shipment at some point vtithin the State, shall not be treated with injections of arsenical
or other poisonous solutions, and no such solution shall be introduced into the blood vessels or cavities or beneath the sur-
face of the skin of any such dead body.
8. Permits for disinterment of dead human bodies shall be void after seventy-two hours have elapsed from date of issue.
9. In procuring transit permits for disinterred dead human bodies the undertaker shall swear or affirm that the remains
have been nrrnared.in,accordancp..wi _t.b.perul c of the_State_.Depa.rtmanr_,of "Ronith
These Permits or Burial or Removal Permits are not to be used as authority for the removal of disinterred bodies from
one district to another either within or without the State. A special form entitled "Transit Permit for Disinterred Body"
should be secured from the local registrar or the State Department of Health, Trenton, N. J.
In all cases where bodies are forwarded by public carrier, notice should be sent by telegraph to the health officer at
destinations, stating the date and train on which the body may be expected. This notice should be sent by, or in the name
of the health officer at the initial point, and is designated to enable the health officer at the destination to take all necessary
precautions at that point.
°The preparation of dead human bodies for transportation by public carriers as provided for in these rules does not preclude the employment of additional
precaution against the decomposition of the remains.