Mattison, Helen Form VS-67 (rev. 11/65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Always write with black ink.
CONNECTICUT STATE DEPARTMENT OF HEALTH
Hartford, Connecticut, U. S. A.
REMOVAL, TRANSIT AND BURIAL PERMIT
(This permit is sufficient for removal of a body to any town and also for interment)
No.of permit
July 23, 1973
Date
The certificates required by the state statutes have been received and recorded, that the body has been prepared in accordance with the Public Health Code.
Permission is granted to remove the body of
Helen Hatch Mattison If veteran
name war
who died at Stamford Hospital Stamford, Connecticut July 18, 197.3
on
Date of Birth Age(in years If under 1 year If under I day
July 30, 1903 last birthday)
Months Days Hours Mins.
69 Se1emale White
Race or Color
Cause of death Pulmonary Embolism
for Burial in Pine View- Cemetery CemeteryGlens Falls New York
in
(Name of Cemetery) (Town)
(State)
Edward G. Lawrence Fun. Dir. 2119 Post Rd. Darien, Conn.
Issued to
or Address
Embalmer
Embalmer's License No. 1h37
THIS IS NOT A CREMATION PERMIT Registrar of Vita( ..:�,
Town of STAMFO•D
'orm V. S. 9
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. 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.