Wright, Lorena Form VS-67 (rev. 7/63)
NEW YORK STATE DEPARTMENT OF HEALTH
Office of Vital 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.
hereby request permission to disinter the dead body of:
Name of ecey�s ed 1 Male Age(yrs.) �" �1'
-fir' a tri 9, 5 _ iJ Female 7Q�u�i?1
Place of Death (indicate whether c)ty, village or town) Date of Death Cause of Death j/
';-cA-17z ./.c.e.�- -r '-'K�r /A S''7°
Ce etery now iId ®1 Loco on (city,town or county)
/j, Is body to be transported by common carrier?
°� NC.t t9 1'0 tie,
fi""v`r //^ El Yes D No
State fully the final disposition to be made of body.
&_ P
Na of place or c tery for final sposition Date of final disposition
��-u,�„a .2 /9'70
Pir Name. / �%�Af-4-~
/
Reg Vo. Address
I - 3 .• C. . fJ2i9/ 17 P f1& ti -
IS tur f f Funeral ^irec r or'lpdertaker ��Ryyeg.No. Date
APPROVAL OF HEALTH OFFICER
I hereby approve the above request and recommend that permission be granted.
1 Dist. No. Signature of Health Officer Date
1
'INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter X/II, 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.