Ketchum, Lawrence 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, 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 Deced Male Age(yrs.)
ret(4f'L14 yt - X-e....e.../..e.A. 0 Female 40
Place of Death (indicate •whether y, zilla4.1 ,,.�^•�^) Date of Death Cause of Death
144/009' .
Ce ..,e/tery now interred `y'Location (city, town or county) Is body to be transported by common carrier?
`.(i � /,° 0 Yes No
State fu y the final disposition �m�f body.
0/0... ..,/..." /..ram .
Fame of place or cemetery f final disposit Date of f al disposition
r l°A f i sC ,/7
,,
F7 Name Reg. No. Address De
nrd
isignat era'Director or Unde ttkerAfi - Reg. No. ate - _ - -
71
e9,.. ,e 24D
,/,2._ /_., _
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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 Officsal 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.