Zrodic, Baby Boy Form VS 61. 1-23-35-25,000 (17.5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL)
This Permit can be signed only by the Local Registrar (Deputy or Subregistr )IoEthxeftpjT
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CfiRTIFICATB OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. p rY Registration District (Town,
Dist.No.......„,1 O-
•
County Town Registered No...........................
..........
Village. . . ..................................................................................................................
Name of deceased.. or City (Ifcity,give street address)
iY iv
....... .. ......
S gle,m ried,widowed, . . .......................................
s
Sex ....Cal or divorced ( .................
write the word) 19... "
Age...._.... . —........................... I?ate of Death` —
onths Days19... ..
Cause of Death................_.. ` Birthplace. ._.....,.•,
....... ...................................................................................
Certificate •••••...--••••••••••••••••••••�..-
was signed by �,ti .........._...................................................................
Address........_ r .........F....
Placeof Burial (orµ .... ............�..................... ............_............................................................-•........M.D.
1,•
(If body is to be Removal) , p ,r � n n _
temporarily held,fill in space later) �`"` �""+"j' �' "'�•••'"""""'""•••
(If body is to be temporarily held,fill in space later)
.Date of Burial.., .G.� d
e Certificate of Death containing the above stated particulars, having been presented Tho me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED
I have accepted the same for registration, have recorded it in my Local Record wi the above stated Registered exam er
and o the basis thereof I HEREBY GRANT A PERMIT BY LAW,
�" �' gtstered Number,
tom.,.,:. ....G.� <
e)
the............. .. ................................_ ...w.
to hold
(Un r er or rson having charge of corpse) teml�orarlly gild,,,• (Address) " "----body..
Dated h
T � "� 19 (Slgne orh wise dispose of[state howj) t e
This Permit iv ,..a: . _. �..............._ • .... L...
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF'
PREMISES ON WHICH INTERMENTS OR
____CREMAT ONS ARE MAD
(Inter ent atior
/� " �
rson
:barge) c�R••K'a••,,.
(Name of Cegtetpty,Crematorium,etc.)
Person in charge must return thii Permit to Registrar of his District within S EN
DAYS from above date. If no person is in charge, the UNDERTAKER MUST
iN ABOVE STATEMENT, write across the face of the Permit the words "No
son in charge," and FILE PERMIT WITHIN THREE (3) DAYS with Registrar
District in which cemetery is located.
EXTRACTS OF THE VITAL STATISTICS LAW
§ 375. Permits for burial or removal of dead bodies. The body of any person
ose death occurs in this state or which shall be found dead therein shall not be
erred, deposited in a vault or tomb, cremated or otherwise disposed of or removed
)m or into any registration district, or be temporarily held pending further dispo-
ion more than seventy-two hours after death unless a permit for burial, removal,
other disposition thereof shall have been properly issued by the registrar of
:al statistics of the registration district in which the death occurred or the body was
und. No such burial or removal permit shall be issued by any registrar until,
herever practicable, a complete and satisfactory certificate of death has been filed
ith him as heretofore provided; provided that when a dead body is transported from
Aside of the state into a registration district in this state for burial, the transit or
:moval permit issued in accordance with the law and health regulations of the place
here the death occurred shall be given the same force and effect as the burial
trmit herein provided for. No registrar of vital statistics shall receive any fee for
w issuance of burial or removal permits under this act other than the compensation
'aided in this article.* Provided, however, that the commissioner of health
have power to promulgate rules with reference to the removal of bodies of
is whose deaths occur on trains, boats or other carriers engaged in the trans-
'on of persons within this state. (Am'd by L. 1932, ch. 267.)
iseietikto`ee section 390.
§ 379. Duties of undertaker. In each case the undertaker, or person having
:harge of the corpse, shall file the certificate of death with the registrar of the district
n which the death occurred and obtain a burial or removal permit prior to any dis-
)osition 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 transportation 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.
§ 380. Duties of undertakers; interment within the state. If the interment, or
other disposition of the body is to be made within the state, the wording of the burial
or removal permit may be limited to a statement by the registrar, and over his
signature, that a satisfactory certificate of death, having been filed with him, as
required by law, permission is granted to inter, remove, or dispose otherwise of the
body, stating the name, age, sex, cause of death, and other necessary details upon the
form prescribed by the commissioner of health.
§ 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 his 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 inspection; 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.
' 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.
arp reauired, under penalty, to report violations thereof.