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transportation of corpseX lj d A w 0 d e� Pr LV d w d V W U NORTH DAKOTA STATE BOARD OF HEALTH TRANSPORTATION OF CORPSE For use only byNorthLicensed (Original) TRANSIT PERMIT O ItiT. 15620 CERTIFICATE OF DEATH state of North Dakota Bureau of vital Statistics Place of Death •Q C`-11-I6-26-10M �'� County...----- ------ ...............__.................. . ----------- ....................... State ...._.._ - ...__............. ------••-•----.. Registered No................................. Township-- ---- - --- or Village ..................... -----------............. ................................ .---------------- or city .._b - - -- - -- — ... - - -- No.......�a....l17 St. ............................Ward (dea ccurredyin� a, hospital or institution, give its name inste of street and number) 2. Full Name - ............. i* . /� (. (a) Residence No..91FO St........ ------ ------- -- ........ Ward ............ .................................................... .. (Usual place of Zr�d (If non-resident, give city or town and State) Length of residence in city or town where death oco......_.... GG_ ..........__.years . ................................months, ................................days How long in the United States if of foreign birth_ ................._... _ ------------- years , -------------------- ............ months , ............... ___ ........... days PERSONAL AND STATISTIC,kL PARTICULARS 3 Sex 14. Color or Race 5. Single Marr e1, Widowed or y" Divercgd "Vi `3 the 5a If Married, Widowed, or Divorced HUSBAND of (or) WIFE of 6. Date of Birth (month, day, nd ear) / �D 7. Age Years 1 onth Days If y / 7 1 8. Occupation of Deceased (a) Trade, profession, or particular kind of work.- .................................. _..._.. (b) General nature of industry, business, or establishment in which employed (or employer) ............................. ...... (c) Name of em 9. Birthplace (city or town)C (State or Country) 10. Name of Father I-(State 11. Birthplace of Father (c' or town) I- (State or Country) W 12. Maiden Name of Mother_ . 1 less MEDICAL CERTIFICATE OF DEATH 1F. Date of Death (month, day, . tv? 17. - 1 HEREBY C TI Y, at 1 atten ed deceased from -- .............. - .LlJ-C-I-... . . ...._. that I last saw h alive o ........... .._... .� ......., 19..�_) and that death occurred, on the date state , at .............................m. The CAUSE OF DEATH* was follows: n \ ---------- ------....._...... - l --------------------------------------- I......................................... ...... 1... --- ._....--- •------•------..... ............. .-------- --- ----------- (duration) .. yrs. ............mos. ............ds. CONTRIBUTORY ...------ (Secondar ) (duration) .... 18. Where was disease Contracted if not at place of death?.....t Did an operation precede deati:?.... Was there an autopsy? ..................�. .......ds. Dateof ............... r........... What test confirme d is? ...... (/( ��'C�` ....--__ :. ...................................... /� (Signed) .............................. .... M. D. (Address) 0 0. ItCZ�r * State the Disease Causing Death, or in deati s from Violent Causes, state (1) Means and Nature of Injury, anu (2) whether _ 13. Birthplace of Mother (ci or town) (State or Country) � Accidental or Homicidal. (See reverse side for Additi�,al space.) �p .eO 19. Place of Burial, Cremation or Removal �y� Date of :lurial s-� 14. r Informant ....................................! d (Address) t s�'.Z� 19(:,.r3 H 15. Filed...........................19........ .............. .......... ............. ........ .. Registrar. 20. Undertaker Address v� f ERIV IT "Ore LOCAL -1104 RD OF HEALTH This Permit must be properly signed and with Physician's Certificate presented to Railroad or Express Agent or other Common Carr before body can be shippe (To include auto transportation.) In the.. of - C1-----------------------County of City or�nship ------... -------- . ""- State of-. .... _�.._. .(. ..............on the -------- ._...._.j -A.... ................. day of --------- �.........� , 19aJ' Permission is hereby given to remove for burial at ---- _'" " O. •----•-- r----.--•---•----------------------------- ---- -- ------ ---------- in the County of---- ----- ------ - - --------• --a'`-- t- .--........ State of._ yLc .`-1 .. the body off s t?-"-----------------------•---��%'I----........ ----................ who died at-.- � t?.............................County of------_- - .. State of__..__ �f j. ,.c _. v�-3 on the.. day of... . f- . --- day _... Aged .....�71_...years._..... ..... months .......................................... days. The cause of d th being....._...--•--••..................................................... which is a .............................. ... .................. ........... -- .......... Disease. wmmunicau or non -communicable To be accompanied by / 4G : , ...... -................................. ..........._.._ as escort Rule 1. The transportation of bodies de of smallpox r bu on' plague from t;ye state is absolutely forbidden. (If City or Town, affix Corporate Seal) Signed. ......................... Health Officer. I- ------------------------- Rules of the North Dakota State Department of Health Governing� Rule 1. The transportation ed bodies dead of smallpox or bubonic plague f from one state Transportation ory, diof i the Dead to another is absolutely prohibited. Rule 2. The transportation of bodies dead of Asiatic cholera, Province croup), scarlet fever, (scarlatina, scarlet rash Yellow fever, cable diseases shall not be accepted for transportation elan, glanders, anthrax, leprosy, fever, diphtheria (a) arterial and cavity injection with an a Y, measles or other hi (Membranous omrmu is absorbent cotton; and roved disinfecting flu d for shipment by being thoroughly di disinfected by a certificate as such a(c) washing the body with the disinfectant —all of which ard of Embalmers.must be done by an embalmer holding ( ) disinfection and stopping of all orifices with After being disinfected as above, suchsbody tate hall be enveloped in a la er of completely wrapped in a sheet securely fastened, and encased in an air -tight zinc, tin, co iron casket, all joints and seams hermetically sealed, and all enclosed in a strong,dry cotton, not less than one inch thick. prepared for shipment by disinfecting and wrapping copper, or lead lined cgffin-'br coffin or casket encased in an air -tight zinc copper, as above may tight wooden box. Or the body being pper, or tin -lined box, ballpji joints and in aseams hermetically coffin or casket, and said Rule 3. The bodies of those dead of typhoid fever, disease other than those specified in Rules 1 and 2 may be received for transportation when prepared fords red. Puerperal fever, tuberculosis or other dangerous communicable arterial and cavity injection with an approved disinfecting fluid, washin Ping all orifices with absorbent cotton, and encasing in a strong coffin or casket and enclosing same in a strong st by p- wooden box, —all of which must be done b an embalmer holdin a certificate casket g the xas such a terior of the body with the same, stop - Embalmers. Y g outside Rule 4. The bodies of those dead from an approved by the State Board of when prepared by an arterial and cavity injection with an stated in Rules 2 with same, stopping all orifices with absorbent cotton, and encasin it. a and 3 may be received for transportation strong outside wooden box, --all of which must n done b Ppencas disinfecting fluid, washing the exterior of the body State Board of Embalmers. y an embalmer holding coffin or casket and enclosing in e Rule 5. In the shipment of bodies dead from an g a certificate as such approved by the properly disinfr;.te Y disease named in Rtae c>�such bod; must not be accompanied by persons or articles which have been exposed to the infection of the d series, unless certified t the health offtr:r a having beeni prevent the 5preaex of th n ' a +ha r:„ t 7 not ti a ase. The transit h �`' ark �P name arr,, health authorities to aces , y Kermit _2 `, �11 na essary p.•erautions ha r bean t= by telegraph by the shi n the remains. In cases v here bodies a. l 1 e� ii c"`zi' who PPi .a embalmer to the health eu officer, or, when there is, na heart :(Doff cer,�to4 otherzomp�sent` authority at destination, advising the date and train on which the body may be eapectedder Rule 2, notice must : •sent Rule 6. Every dead body must be accompanied b and also present a full first-class ticket marked "Corpse"Y a person in char physician's or coroner's certificate, name of deceased, date and hour of death whomustbe ,,•a 4 all oilier items of the standard certificates of deathrecaainnerid aabipo�tation of the body a ci a ra a passage ticket adopted b Y u a tra, ut permit showing p Y the United Stags Census Bureau, as far as abtainabie, i.. V, ne 1g.�tan ace o c,ia h use of death, and removal, whether a communicable or non -communicable dice t e Ame ican pu , i� Real, is caused by any of the oat , Association and to accompany diseases specified in R.ul ase, the h sf.c o „� p y the bod point to which the body is to 7 shipped, aTs perm`, for Y• Also the undertaker' es 2 and 3 the names of those authorized by the health authorities transit certificate as p how the body has been prepared for shipment. The permit must be made in duplicate and the signature pat be on both the original and duplicate co g ure of physician or coroner, health officer andMdertundertaker must be detached from the transit permit and securely fastened akerthe rre is thescerti icaoffin t an bided with at least four handles g The physician's certificate and transit d Paster of the original shall char e of the Corpse. Tne -who:,- U;,plicate co permit shall be handed to the All coffin boxes must be pro - initial line, and by h�;=;: Co <<,� �eC1,;t py shall be sent to the official in charge of the baggage said shipment is rriade rY of the state or provincial board of health of the state or Passenger in department of the Rule 7. When bu ' province from which The undertaker's cer, 'xpress, a transit on the coffin box. Th ster of the original shall beidetached from inRule transit L t `1 ; ust be made Out in covering ths. emair. - :an s certificate and transit permit shall be attached to and 'accompany the express duplicate The whole '' wnd be delivered with the bodyPermit and securely fastened ieate copy shall be sent b at the point of destination ,o the of health ; Y the forwarding express agent to the secretary of the state or provincial board state or province from which said shipment was made. Person to whom it is consigned. Rulc• �. disinterred body, public tie; .�h ar:•� shall not be o epddedd from any unless said removal has Y disease or cause, shall be treated as infectious or dangerous to the vincial ,earth ,;,;tho all n ha the loc-ality to which the corpse is consigned has first been obtained; and all such die cterre having jurisdiction where such body is disinterred, and the consent of the health authorities of casket cont:.ming the same, must be Wrapped een approved by the state or pro- pped in a woolen blanket thoroughly saturated with a 1-1000 solution of cor- rosive sublimate, and enclosed in a hermetically soldered zinc, tin, or co vaults shall not be treated and considered the same as buried bodies, when originally bo re d remains, it the coffin or as defined in Rule 2 or as di_+•ected in Rules 2 and 3 copper -lined box. shipment takes place within thirty But bodies deposited in receiving abev (according to the nature of the disease c causing by a licensed of e directed by Iicen� r: ,, a y days from the time of death. The shipment of bodies aL, al..ers fror, receiving vaults r7 death), Provided - be made witbi t ;r, Prepared ,in the manner the casket or coffin box cuntainmg said body must be en�,:Iosed' in t hermetically soldered box. - .9 C�Vs from r; death without Rule 9. All rules and .,:, .wry,,:, v i:�:r--lie uua5. parts of rules conflicting with these rules are �� cirtrty ua45 hereby repealed. A. A• WHITTEMORE, M. D. Secretary and Executive Officer.