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(56)
FORM OP APPLICATION
to be filled in by persons desirous of depositing bodies
in the mortuary provided for the parishes of st. giles
in the fields and st. george blooms bury.
TO THE BOARD OF WORKS FOR THE ST. GILES DISTRICT.
Gentlemen,
I, the Undersigned,
of No.
do hereby request you to receive into the Mortuary in
Goldsmith Street, the body of
(* )
late of No.
who died 011 the day of 188
at
the cause of death being
And I hereby undertake to remove such body for
interment within days from the day on which such
death occurred, and to abide by the Regulations of the
Board in respect to such Mortuary.
Dated this day of 188 .
Applicant.
† of the deceased.
* State whether Male or Female.
† State whether Undertaker, Friend or Relative (and if so, what) of
deceased.