White, Harold rm VS-67 (rev. 7/63)
NEW YORK STATE DEPARTMENT OF HEALTH
Office of Vita! Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
In completing this form, please typewrite, hand-print or write legibly all entries in permanent black or blue black
ink. Signatures should be legible. This is a permanent record. When data cannot be obtained, write "UNKNOWN"
in applicable spaces.
I hereby request permission to disinter the dead body of:
Name of Deceased 14
L laie Age(yra.)
a.—o 1 f 1 k) ( Jc� LJFemale C
Place o r'eath (indicate.whether city,/village or town) Date of Death Cause of Death
et y v+- 6 Icii S Fc€ 1 i„ y /vJ 7/73 C.Gc v SLC t1 a..r a.. o 4' G 1,-,„--
cPVCeI
etery interred I,o ation (city,town or county) Is body to be transported by common carrier?
rz Ut,,,t1 7n j uteits ✓`f//J 7 E1 Yes -No
t,tate fully the final dispositi to be made of body. r 11
7J �
F1 IJ G 1 !'t —— -
lea a of place or cemetery,..tv final disposition. Date off inal 4isposition
fl/rs G°Ieh� i1��
en.c.frc,r, 11L173
pN• e e, Reg.No. Address ,v/ / .
1 vnrt.�c Se icy t�lY7� (36(a.V/c•, Sf G— kb,
Sigma of Funeral I•irect o '7n 3ta i Reg. No. Dste
APPROVAL OF HEALTH OFFICER
I hereby approve the above request and recommend that permission be granted.
1)ist. No. Signature of Officer Date /
� ' y�; 5/f3/73
'INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter XIII, subdivision 4) of the Sanitary Code, relating to the transportation of dead bodies
by common carriers, as printed on the back of the Transit Label.
2. Permission for disinterment must always be obtained whether the body to be disinterred is to be transported by common
carrier or by other means.
3. The data required concerning the decedent may be obtained from the local register or cemetery record.
INSTRUCTIONS TO LOCAL REGISTRAR:
1. For bodies to be transported by common carrier, fill out Transit Permit.
2. For bodies not to be transported by common carrier, fill out ordinary Official Burial (or Removal) Permit.
3. In each case write the word "DISINTERMENT" on the Permit.
4. This form should be filed and carefully preserved in your office.