Hall, Thomas Form VS-67 (rev. 11/65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
In completing this form, please typewrite, band-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.
1 hereby request permission to disinter the dead body of:
Name of Deceased ogi Male Age(yrs.)
4/ � Female J _
Place of D athth(indicate he r city, villa,a or town) Date of Leath Cause of Death
./Se4°Y1-40
Ce .etery now interred Location(city,town or county) Is body to be transported by common carrier?
Li. J/,I� .G.G�rt Yes No
State f ly the final disposition to be made of bdody.
b470•%ereos-s-e-.11-',..04-2r:, #L*P ea•••--•
Name of.place or cemetery for fi 1 dispositio Date of final disposition
‘--f-7//
Fir N+ke r Reg. No�j Address
rP�.%-i A te, �iy
:Si of Funeral Dir for or On ertaker Reg. No. Date
J/ DJ��f3- f/dl7 G
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter X111, 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.