Disinterment Request
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Disinterment Request
In completing this form, please typewrite, print or write legibly all entries in black ink.
Signatures should be legible. This is a permanent record. When data cannot be obtained, write "UNKNOWN" in applicable spaces.
I herebj requestpermission to disinter the remains of: DMale D Female
Name of deceased
Age LliJ If under 1 year U U If under 1 day U U
years mos. days hours mins. wD1ate fderw
Place of death (indicate city, town or village) mo day yr
Manner of death
DYes DNo
Cemetery where now interred Location (indicate city, town or village) Is body to be transported
by common carrier?
State fully the final disposition to be made of the body
LIJynalldisrritio1 I
Name of place or cemetery for final disposition mo day yr
Firm name Registration number
Address WWW
Signature of funeral director or undertaker Registration number mo day yr
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER
1. See Section 13.1 of the Sanitary Code, relating to the transportation of human remains by common carriers.
2. The data required concerning the decedent may be obtained from the local register or cemetery record.
3. Complete DOH-1999 providing information concerning the final disposition of the remains.
INSTRUCTIONS TO LOCAL REGISTRAR
1. Complete Disinterment Section of DOH-1555 Burial-Transit Permit.
2. If death certificate is on file in your office, use form DOH-1999 to correct the disposition information and forward
form DOH-1999 to the Coding Unit, Vital Record Section, P.O. Box 2602, Albany, NY 12220-2602.
3. If the death certificate is not on file in your district, forward form DOH-1999 to the Coding Unit, Vital Records Unit,
P.O. Box 2602, Albany, NY 12220-2602.
4. This form should be on file in your office.
DOH-2699 (2/2003)