Covell, Harry Fornr i-67 (rev. 11/65)
p,
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.)
'V M. CRv ram- -
0 Female
Place of Death (indicate •-+hether city, village or town) Date of Death Cause of Death
City of Punta Gorda, Florid .
Cemetery now interred Location(city,town or county) is body to be transported by common carrier?
_. , EiYes E3 No
State fully the final disposition to be made of body. """ 4
Interment
Name of place or cemetery for final disposition �y #.,.� Date of final disposition
- :i6 l.d.';, ✓;;m :pt _ n Tn of Hartford, N.Ye --t/•
a, '-1ii.
Firm Nance - -r
Reg. No. Address
egan &g Denny,Inc. a 028$3 Quaker Rd. ,Glens Falls, N.Y.
Signature of Funeral Director or Und ker�j Reg. No. Date
/ 7 li
4/24/7 8
•
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter Xl!!, 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 Officjal 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.
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
VITAL STATISTICS
APPLICATION FOR BURIAL-TRANSIT PERMIT '
NAME OF First Middle Last DATE Month Day Year
DECESD
(ypeAor print) HARRY _ M. COVELL DEATH February 6, 1978
PLACE OF DEATH CITY, TOWN, OR LOCATION NAME OF (If not in hospital,give street address)
COUNTY Charlotte Punta Gorda. NSTPTUTg Medical Center Hosp.
Attending Physician t) (Name of Medical Certifier) (Address)
Medical Examiners ❑ Dr. Stanley Spoont, 525 E. Olympia Ave. ,Punta Gorda,Fl 33950
Funeral (Name) (Address)
Home KAYS-PONGER FUNERAL HOMES,P.A . , 619 E Marion Ave. ,Punta Gorda,Fl 33950
Check A ® A completed certificate of death accompanies this application.
One
B ❑ Dr. was contacted on - , 19
He has assured me that this death was from natural causes and that he will complete and sign
the medical certification of cause of death.
C ❑ The attending physician was unavailable or this death comes within the Medical Examiners
jurisdiction. The body was released to me by
on , 19
(Signature) (Fla. Lic. No.) (Date Signed)
Funeral 0/
Director Q se FE 1644 February 8, 1978
RIAL TRANSIT PERMIT Permit 432B-168
No.
Permission is hereby granted to dispose of this body by burial, transportation out of state, storage or cremation. For
cremation a waiting period of 48 hours after death must be observed and the Medical Examiner's approval must
also be obtained.
❑ A five day extension of time for filing the death certificate has been requested and granted.
Signature o Date
`� i`�'"
Registrar �� Issued February 8 , 1978
CEMETERY OR CREMATORY
Method of Disposition Date of
❑ 1 RIAL Disposition 1; /9 e
❑ REMATION
STORAGE Place of -� 1j ,��
❑ OTHER (Specify) Disposition
Signature of Sexton
or Person in Charge -, (il•
This permit must be endorset by the sexton or person in charge tor by the funeral director when there is no sexton)
and returned within 10 days to the local county health department.