HomeMy WebLinkAboutdeaths records form blank (3) t
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TRAN S1 1 �.-• .
EPTED Part,,.S No.ez
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
leath calls for a coroner's
't show whether the me. [$' A Transit Permit and Transit Label issued by the Local Registrar of Vita[ Statistics must accompany �'
dead body transported by common carrier.--Rule L
rer If the former,
nethhee r the death calla for PERMIT OF LOCAL REGISTRAR
ust make it clear whether Registered No---------------- ---- —
Test1gation, The cause of -------- __ Lq
-ery unsatisfactory state- DISC. No•---
Date of issuance_________________..__..�___._...�--•--
ng death?
always be stated especi.
4dbearing age. dues the J A satisfactory Certificate of Death having been filed and recorded in my office for_________________.__._..__.____.__.______________
c.? The certificate must
tt calls for a coroner's -----•--, who died in the_____.-----------•-----------...--••--._._.._of-_-__-. --
----------- (City,Village or Town) 19__—., and
ase should be stated, as of_____--__- -------__._--------••-----•...................... State of New York, on.-•------......_._...__..-------••---•--••_-__...
etc., and the certificate a County y-------- (Name sod
ails for a coroner's in- sl the body having been prepared strictly in accordance with RULE-_-----•---•- as certified b
-_ ------_ .-__-___-__"Shipping Undertaker, PERMISSION IS HEREBY GRANTED
�iways be stated, eapeM- ° escort
dbearing age. Was the -
:? The certificate must y�, address of Shipping IIndertaker)
th calls for a coroner's v7 FOR THE REMOVAL AND SHIPMEIIT OF THE BODY OF SAID DECEDENT; Na
o - _ N-__- Point of 4
Point of Shipment-------------------------------------------------------
ease of the spine or of ---•------------------•-------•--- -- -
cte of the disease? If a
••- -
----••----
t fact should be clearly 3 Destination__.._--_-.-----•-- -
A stillbirth is a ehf1A � (Signature of Local Registrar).____-..__.___..______-_ '�-
— ---"
ently received in which
---...,County of-------------•______________
tated for a "stillborn" ;
11
Local Registrar of the._______Village or Town)of-___....___-•-•.
ether the child was In (City,
?rrect the statement of 0 State of New York. (y 7'
ent of age is found to ING
" ROUT and some 4 V
It is usually of the I S ent must enter hereon a description of the ticket S id by the passenger in charYe :��i•� .
cified. I s ortation Ag '
sod? ; The Railroad or other Transp the exact route,and VIA WHAT JUNCTIONAL POINTS it reads.
the operation under- of the corpse, pr
requiring a surgical and an Undertaker's Certificate stating that the body has been prepared for shipment in accordance with 4 �� iS ,
Srsc[nr Ixsrxvcrtovs—A burial case containing a corpse must not be received for transportation unless the person in charge esehip a Transit Permit issued
ie assumed, as a rule, bi. the Local Registrar of Vital Statistics (Rule he
• i from the case. „
I
�me disease or injury, �..__----•- 9
Date...................................... r
7cnce the operation IC the Laws of the State;nor should it t,c teccivc[S oven then if any fluids or offensive odors aro escaping ,
�le cause of death. A •••..............
--•--- -,"State of---------•---• • ----------_—
administration of State o£ New York,to 1
the a
From_.._.-•........................•--•-.•_.__..-----_..._ ._Form No. of Escort s'ricicet.....__.._...__........_.._..___.._._...--•------••-._...._-------- -• �,ay ,
and the
to
a an injury "ham.
the death calls for i No.of Escort's Ticket_.................•-•••--•••••-••-~-""""--"•'""-••-�•�•-•••-• •
-•--....--•.............Form No.of Corpse Ticket._.._.._...._..._....._._.-----•--•----•---------•---•--_..__._..-------•-- �
......
t. G
No.of Corpse Ticket
cancer or a bontgn _.__._... -•- - -----•
�Qected should always
Via To..............__..._........._.
)bold fever or p ----------------------------------- ...................
as cerebral Via..-•------------••--•---••----•--•-----------•-•-•-••---._..----•--••-----------•---•--•-•-------•
..__._...--•----•---•--•--....-------•- 'r'lace of Residence...................... .
3lsease of the spinal ---•_----Shipping Agent
what Name of Passenger in charge-__-_-- •_.__,._ .
_-__---- — y A