Crammell, Pearl Form VS No.67. 9-16-30-5000 (17-1827)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER'S REQUEST TO DISINTER BODY
: 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. 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________________
-----P� --1Jtl
/� - - - - - - who died in the * - - -
�- ----• Q (Cit Village, wn)
of---- - ----- ---------------on*--�1-�---�---1-���., Sex,-�'... '.10
Color o race* W , Age*___/___7-_____.years, and Cause of Death*------------------------------
1e ----------NOW INTERRED IN___ __
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(a) The body is to be TRANSPORTED BY COMMON CARRIER for-----� a
--------------------------------------------------------------------------------at----- --- _ -�tJ P�------a
(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______________________
- ----------------------------------------at----------------------------------- -- -- -
(State fully the disposition to be made of body) (Name of lace or cemeterY;
(Signature of undertaker)------- .1...�1�_ ___- /--- --- - --------------------------
Dated.-----0-- ---- J ------19.1--3_ Address---- -------
License No.------- -- J --------------------------------
APPROVAL OF HEALTH OFFICER
Dist. No.:6-f-7--------- ._..____-------------------
` _ \_
I HEREBY APPROVE above Request an reco en hat ermission be gran
_---_----�----
ignnature o�ealth Officer)---------------- -- ---------------- ----- ------ (--------------
Date - ...
--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 can not be obtained.
The Disinterment blank should befiled and carefully preserved in your office.
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