Pruyn, Alice Form VS NO.61. c-1P•31-7o.uuu lii.owro,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
aaTThis Permit can be signed only by the Loral Registrar(Deputy or Su strar)of the Primary Registra- e
tion District(Town Villa ,or City)in which the death occurred after the FILING and aeseptanee of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. t
Dist No.....869.L _ RegistNot ., s
county Warren ate of Death.. _.. /
Town,Vichy of Wens .. 7. � �., e _
lage,or City-
(If ' s— ----- Age. Yrs. Color..
citygive street a / Moa.
Cause of Death a ge - -.- -.-- --.-.-.___
` `
Place of B emov .LLB
I ___._Date of Burial.. . _ /7 19id/
Cemetery . _ .�... eCL_f
Certificate of Death of_ (Give fe ---- -- ----� -- -- - -- • ---_._._.._.._.........._.._._
having been presented to me containing the above ppa d after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I ve accepted the same for registration,have recorded it in nay Local Record with
the a stated Register crs , o the basis thereof FREBY GRANT A PERMIT
(N a tut ) ,
the__. ._ ._ ------__..__to __
(Uri or person hgvtng charge ) (In qr to how.
Dated--_-_._._b.,-- --.----19--- / (Signed).
eis _.__._. ...
Th Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the
State (subject to local cemetery or other regulations),unless remora:is by common carrier,in which case a
Tr-..-tt Ar....O.Ale 1111...a91 i-.r....tru.l
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF,PREMISES ON WHICH IPR-
MENTS R CREMATIONS ARE MADE
bate of -/ /7 _fir
t or
(Name of Cemetery,.. „ ... (") 47.4046.A.r: 4=4
Person In charge mast return this Permit to Registrar of hie District within
SEVEN(7)DAYS front above dab.: f ao person is in charge,the UNDER-
TAKER MUST SIGN ASORESTATEMENT,write across the face et the Permit
the words"No person In charge,"and FILE PERMIT IMMIX THREE(3)
DAYS with Registrar of District in which cemetery is located.
EXTRACTS OF THE VITAL STATISTICS LAW
i 379. Dudes of undertaker. In each case the vJn uandertaker' or person
g of the ROMDse,shall file the certificate of death with tie registrar
the ilia ct in which the death occurred and obtain a burial or removal
the to any din tiops�is e e. O The undertakerb shall
e
witlrn tile state off key York,it shall be • t vered to the peran ht ohs*Se'
of the place of burial. ,
f 3110. Duties of undertakers; interment within the state. If the inter-
ment or other disposition of the body is 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,hating
been filed with him,as required by law,permission Is granted to inter remoye
or dispose otherwise of the body,stating the name,age,sex,cause of death
and other necessary details upon the form proscribed tyr the m issioner of
381. Interments. No-person`in charge of any on which
interments or cremations aremac�e sham inter •or t th stor other
tr o t Any body.n rein Provided. Such person'alllr endorse .crtn h star
the date of interment,or cremation over his signature,and shall return add
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 under his charge,in each case statingthe name of each deceased p prank/is of death, data of or dispo
and name and address of un which record o va'.at all times be
to,ofi i provided al inspection; provided the undertaker or person'gbenne
charge of the corpse,when burying At body in a burl
having no person in charge,shall sign the burial or removal permit giving
the dateof burial and 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 of the distract in which the cemetery is located.
Ile'SEXTONS and UNDERTAKERS vio the law • to e
bun of are lte a to a penal of NOT
NOR O�R THAN ] DOLLAR FOR >�'i , i
law will S..n erase.i. Local Itadstrars,are rotated.nailer
aroLtlena tharsef.