Simpson, Amos Form VS No.61. 1-20-30-75,000(17-4362)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'This Permit can be sigmd 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 CDR.
RECT AND COMPLETE CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.br_sf_i Registered No....................
County (5.-2/.14.t.... Date of Death1.4..../...e...._....tg.32
Town,Vii- .
-,--Tt2:,...)...e......i. Self42 Age. 84 i Yrs. Color Lel-c.& .
lage,or City- (Or Mos.)
(If city,give street addres_ye").„6. ._,, eLoorie...„2,2e2 jikz..
Cause of Death_ ef--- if-I' .---
-
Place of Buiial(or Removal) _-i.e..-t.,,, (29/As
- Ft Date of BuriaLii.a.-4-e_l_......z9.21
Certificate of Death of e6rde1—e.17.-.i.t "CilL7Yereceae-q-v-as1
(Give full name of )
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 above stated Registered Number,and on the basis thereof I HEREBY GRANT A PERMIT
...., ....... ..i....
i 7_,„„ 14....
,
us 6:(....=04.44,aktzt....rf unde ), ,, (Address)
the. to. --ttieta..&/.., the body.
(Undertaker person having charge of corpse) (Interiemoe,or o ,rwiseo=rje of[state how])
Dated—... e.-ta__ Li 1931 (Signed). -VP)22 I-''''".
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any which
of the
State (subject to local cemetery or other regulations),unless removal is by common carrier,in case a
Tr.sonsit PVIV•^Y•41./VC P&L% Csl:----s--•
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENT , •R CREMATIONS ARE MADE
Date of .,aaaw ay .,,...-----...,.s
,1211111. anion)
(Signed). f � 41:timernseflofy
(Person
in
age) ~14' (Name of Cemetery,Creinato ,etc.)
Person in charge must return this Permit to Registrar of his District vitae
Om(7)DAYS from above date. no person is in charge,the TINDER.
TAKER MUST SIGN ABOVE STATE T,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 ocgurr'ed and obtain a burial or remooval.
permit prior to any disposition of the bod . * * * The undertaker shall
deliver the burial permit to the person charge of the place of burial,before
interring or otherwise disposingof t body; or shall attach the removal
permit to the boa containing the corpse when shipped by any transportation
company; said permit to accompany corpse to +�.� ,destizA'on,whet*' if
within the state of New York,it be delivered to the pe in charge
of the place of burial.
880. Duties of undertakers; Interment within the state. If the inter
meet,or other disposition of the body is to be made within,the state,the word-
leg;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 flied 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 rnmmiseioner of
1381. Interments. No person in charge of any premises on which
interments or cremations are made shall inter or perimt 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,pe of death, date of burial or disposal,
and name and address of the and which record shall at all times be
open to official inspection; provided t the undertaker or pee son having
charge of the corpse,when burying a body in a ePreetery 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 cr removal permit within three days with
the registrar of the district in which the cemetery is located.
[ ir SEXTONS and UNDERTAXERS violating the law relative to
tarn of permits are liable to a penal of NOT LESS THAN FIVE DOUARS
NOR MORE'THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
law wall be enforced. Local Registrats,ere required►under penatbs to ro
violations thereof.