Morgan, Baby Girl • F J
Form VS No. 67. 7-31-29-5000(17-848)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
Fe-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
Stillborn Baby licga.tr who died in the * city
- ---- ---.---�-�t
(City,Village,Town)
of Glens Fa lls,1T.Y• on * January 28th, 1934 , Sex female
Color or race * bit.e. , Age rbillborytars, and Cause of Death *
Dystocia NOW INTERRED IN Pine View Receiving 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 be transferred
'Tr`-_ _.a kc-a.__he =°_se for interment at Glens Falls Cemetery ir .50./r/.3%
(State fully the disposition to be made of body) (Name of place or cem- )
��'s(Signature of undertaker _-- -!-I m�tiere $7) 1/
Dated April 30th I9 34 Address14 Glen St, Glens Falls , N.Y.
License No. 5342_________
APPROVAL OF HEALTH OFFICER
Dist. No .rt j 7
I HEREBY APPROVE above Request a d recommend th Pe 'ssion be gra ted.
(Signature of Health Officer) 61*
Dated Apx'it 30th. 19 34
'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 ^htained.
Ar =ram