Butterfield, Oliver Form VS No.67. 8-20-25-5)00 (21-1315)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
ESP See 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
, who died in the *
(City,wage,ppm,tet<
of on *,a1A- 0'7,-,49"-- 51 ,
Color or race eZe_gLeiG. , Age * r(io' years, and Cause of Death *
NOW INTERRED
(a) The body is to be TRANSPORTED BY COMMON CARIfER for
at
(State Jl1y the d osition to be made of body) (Name of place or cemetery)
(b) Th bod is NOT to be transported by Common Carrier but is to be
a.-toe at. - —
(State fully the disposition to be made of body) (Name of place or cemetery)
(Signature of undertakerra.44 er—tA4—
Datecl, 77 193 4-) Address. 92-.71 -
License number 1 C3 ct
APPROVAL OF HEALTH OFFICER
Dist. No.Nrg
I HEREBY APPROVE above Requekand recommend that Permission be granted.
zie_7(
(Signature of Health Officer)
Dated 1/21-17 a 6
affinsttuctions 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 can not be obtained.