Peterson, Lorriane c Va u1 v o LV V.el. 1-L0-ZB-/O,UVt)tll-431)ti)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District(Town,Village,or City)in which the death occurred after the FILING and acceptance of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist NOi_ .2_421-- Registered No
County_!l� - r ( . Date of Deat / f I
lage, «/`�1 . - Se �Age Color( 5!_. G _
To war,Vil-
or C}>it_,_ ...
(If city,give street address)/._� ( )
Cause of Death de
Place of Burial(or Remove )
Cemetery t(}Jr4LJ _.... . . . .... .. . Z L. Date of Burial_ _ _ _ _ -..__4? igs ;�J
Certificate of Death of___.._ r i)
(Give full name of deceased)
having been presented to me containing the above stated particulars, and, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I have accepted the same for registration,have recorded it in my Local Record with
the a ove stated Register umber n on the basi thereof I HEREBYL N7'A PERMIT
to tlf -fti..� XJSJQ ///l
( me f dertak �! )
the to A the bo y.
( ertaker o erson h ing lye„Eg_e o c7se) (In er re ove,or othe wi dispo c f Estate ow])
Dated ___zsr- (Signed)_-. . L(_ --
This Permit is sufficient for the Removal (and Interment or Cremat on) of a body to any part of the
State (subject to local cemetery or other regulations), unless removal is by common carrier, in which case a
Transit Permit(VS N„_g91 is...-........1
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Dateof._ .. --
(Interment r (Interment or cremation)
(Signed) _ _ _._—
(Person 7646. tAll4.
in charge) ,
(Name oltCembtery,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his District within
SEVEN (7)DAYS from above date. If no person 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 located.
EXTRACTS OF THE VITAL STATISTICS LAW
§ 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 Cody. * * * The undertaker shall
deliver the burial permit to the person ih 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 Ube 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 inter-
ment,or other disposition of the body/3 to be made within the state,the word-
ing.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 it 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. Suh 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 is district within seven days from the
date of interment or cremation. He s tl keep a record of all bodies interre
or otherwise disposed of on the premise under his charge,in each case stet"
the name of each deceased person, pla of death, date of burial or dis
and name and address of the undert ; which record shall at all times; 'j
open to official inspection; provided at the undertaker or person havin
charge of the corpse, when burying a ody 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.
fair SEXTONS and UNDERTAKERS violating the law relative to the re-
turn 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. Local Registrar},are required,under penalty,to report
violations thereof. ,