Swears, Ella Form VS No. 67. 7-31-29-SM (17.848)
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
LU-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.
f I HEREBY REQUEST PERMISSION TO DISINTER the dead body of________________
,'ll Lae Swears * city
------ ------------------- -------- ----------------------------------- who died in the ------------- -
(City,Village,Town)
of...Glens Falls, N.Y. on * January 7th, 1934 1 Town
- ----- ------- ---- ----------------------------------------------------------------, Sex--------------------------
Color or race *____white_____________ Age *__2_�__--_____years, and Cause of Death *__epi?i-ptic_-
-
_-NOW INTERRED IN-.-Pine view Receiveincr Vaalt
-• r i -
(a) The body is to be 'TOPORTED 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 by
mot (", '4' rll eus ,
.....s��___'.lu;J.i;-$� ��r '�?1r13i 1ri a. gra.�e rlt. Hermance i.elllv'`tt3i3T, -���t--�s.t.�� T'�1�.,
----- - -----------------------------------------------------at--- y--------------------------------------- -------------------------------11 +
_. .Y.
(State fully the disposition to be made of body) ,� (Name of place oor cemeter
(Signature of undertaker L � -- ,
Dated--------&art...7.__23xd---------io,__34__ Address___21 nsFalls ,- --- ---- ----------------- SLY.
License No-------5302--_---
--- -------------------------------
APPROVAL OF HEALTH OFFICE
Dist.
I HEREBY APPROVE above Request- hat Permission-
(Signature of Health Ofl`icer)--------------- --- - ----------- --- �1
Dated__April 23rd r
-------------------------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.
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