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Middleton, Carl FlinAt NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT [sr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District n, Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF E OF DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK. 'fin Registered No. /� Waage Dist. No Cg4�.County. r . .. ..... ... ^ (IL city, e street address) Name of deceased y Vet an '— Sin le, married, widowed, /t/ // veteran, give newel War) ��� g G�/���C Sex... .... .j. .�olor..�,�{! or divorced (write the word). Date of � ath' ..Q 19.�1:F. Age 4. Yea '7 Months...:jr....... .......Days Birthplace. '- . r -0 Cause of Death.. Certificate was signed by... . M.D. Address Place of Burial r Removal) � ... ,,, ,j,,,yearevs....(If body is to bet po arily held,fill in s a t ) nCemetery L� Date f Burial / O19 .fi(If body 1s to be temporarily held,fill In spat ater) The Certificate of Death c. ntaining the above stated particulars, having been preto me, after careful exami- nation, the :me appe•-,r:.:1g to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have ac •'• the same r re ".. r- ':n, have recorded it in my Local c with the a e a d Registered Number, + . b ."th eof RE:Y GRANT A PERMIT d, the /y f/ N " ' , /: r-77 to hold temporarily and Y ..� he body. ( .4 er or pe hn.% y chary rpm) t��//lint or o erwi en state h ) Dated i 19. (Signed) mil.//_ Local Registrar This 'ermit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su set to local cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. )t) • NDORSEMENT OF SEXTON OR PERSON IN CHARGE OF i: PREMISES ON WHICH INTERMENTS OR ,CREMATI AR E Date'of. ' • (/ tQ...._. ...i9 (f�!errn,,., (Signe .. .. .. .. (Person • in chars c.�i1a,Q .T' �J (Name of Cent. .) Person in charge must return 'his Permit Registrar of his District within SEVEN (7) DAYS from above date. `If no erson is in charge, the UNDER- TAKER MUST SIGN ABOVE STATEMENT, write across the face of the Permit the words "No person in charge," and FILE PERMIT WITHIN THREE (3) DAYS with Registrar of District in which cemetery is l,,cated. EXTRACTS OF THE VITAL STATISTICS LAW § 375. Permits for burial or removal of dead bodies. The body of any person whose death occurs in this state or which shall be found dead therein shall not be interred, deposited in a vault or tomb, cremated or otherwise disposed of or removed from or into any registration district,or be temporarily held pending further disposition more than seventy-two hours after death unless a permit for burial,removal. or other disposition thereof shall have been properly issued by the registrar of vital statistics of the registration district in which the death occurred or the body was found. Nu such burial or removal permit shall be issued by any registrar until, wherever practicable, a complete and satisfactory certificate of death has been filed with him as heretofore pro- vided; provided that when a dead body is transported from outside of the state into a registration district in this state for burial, the transit or removal permit issued in accordance with the law and health regulations of the place where the death occurred shall be given the same force and effect as the burial permit herein provided for. No registrar of vital statistics shall receive any fee for the issuance of burial or removal permits under this act other than the compensation provided in this article.* Provided, however, that the commissioner of health shall have power to promulgate rules with reference to the removal of bodies of persons whose deaths occur on trains, boats or other carriers engaged in the transportation of persons within this state. (Am'd by L. 1932,ch.267.) • •See section 390. § 379. Duties of undertaker. In each case the undertaker, or person having charge of the corpse,shall file the certificate of death with the registrar of the district in which the death occurred,and obtain a burial or removal permit prior to any disposition of the body.*** The undertaker shall deliver the'burial permit to the person in charge of the place of burial, before interring or otherwise disposing of the body; or shall attach the removal permit to the box containing the corpse, when shipped by any trans- portation company; said permit to accompany the corpse to its destination, where if within the state of New York, it shall be delivered to the person in charge of the place of burial. § 381. Interments. No person in charge of any premises on which interments or cremations are made shall inter or permit the interment or other disposition of any body unless it is accompanied by a burial, cremation or transit permit, as herein provided. Such person shall endorse upon the permit, the date of interment, or cremation over his signature,and shall return all permits so endorsed to the registrar of, his district within seven days from the date of interment or cremation. He shall keep a record of all bodies interred or otherwise disposed of on the premises under hi.,, charge, in each case stating the name of each deceased person, place of death, date of burial or disposal,and name and address of the undertaker; which record shall at all times be open to official inspec- tion;provided that the undertaker or person having charge of the corpse,when burying a body in a cemetery or burial ground having no person in charge, shall sign the burial or removal permit, giving the date of burial, and shall write across the face of the permit the words "No person in charge," and file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. t5 SEXTONS and UNDERTAKERS violating the law relative to the return of permits are liable to a penalty of.NOT LESS THAN FIVE DOLLARS NOR MORE • THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced: form VS 67. NEW YORK STATE DEPARTMENT OF HEALTH ALBANY UNDERTAKER ' S REQUEST TO DISINTER BODY I See Special Administrative Regulation 1, subdivision 4, Relating to the Trans- portation of Dead bodies by Common Carriers, as printed on the back of TRANSIT LABEL. N. B. Permission for disinterment must ALWAYS be obtained whether the Body disinterred is to be transported by Common Carrier or by other means. I HEREBY REQUEST PERMISSION TO DISINTER the dead body of Carl P. Middleton , who died in the*. City (City, Village, Town) of Glens. Falls on* Tan. 8th.,..1.94$ , Sex.Mae Color or race* H' , Age* 65 years, and Cause of Death* .Bron.c.ho...pneumonia NOW INTERRED IN Pine View Cemetery Vault (a) The body is to be TRANSPORTED BY COMMON CARRIER for • at (State fully the disposition to be made of body) (Name of place or cemetery) (b) The body is NOT to be transported by Common Carrier but is to be transported by motor coach for burial . Bran La,:- C-eme Brant Lake, N. Y. (State fully the disposition to be made of bed ( m place of (Signature of undertaker) • Dated..March..3.0th, 8.. / Address....'.. - •n St. , Glens Falls, N.Y. License No. 4493 APPROVAL OF HEALTH OFFICER Dist. No. I HEREBY APPROVE above Request and rec mmend that Permission be granted. 777 of (Signature of Health Officer) HEALT OFFICER -- Queettsbury, (y. Y. Dated May 19....4g, 7 Instructions to Local Registrar: Fill out (a) Transit Permit for bodies trans- ported by Common Carrier or (b) ordinary Offical Burial (or Removal) Permit for bodies not to be so transported, in each case writing the word"DISINTERMENT"on the Permit. The data required concerning the decedent may be filled in from the local register or cemetery record. When data can not be obtained write "Unknown" in spaces in- dicated by (4'). The Disinterment blank should be filed and carefully preserved in your office.