Philo, David Form VS-bl (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, 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 Male Age(yrs.)
0 Female
Place of Death (indicate •"ether city, village or to,vn) Date of Leath Cause of Death
City of Glens Fall _= '' 1 %� -
Cemetery now interred j.ocation(city,town or county) Is body to be transported by common carrier?
- Vault of Queensbury,NY 0 Yes Q No
State fully the final disposition to be made of body.
•
Interment
Name of place or cemetery for final disposition luate of final disposition
-
ide Cemetery, 5/6/7c
Firm Na ce
Reg. Po. Address
Regan & Denny, Inc, at 3r r.
;Signature of Funeral Director or nde er - t Reg. No. Date
O147 5/ /78
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 b ; filed and carefully preserved in your office.