Moss, Nelson Form vs 1Vo.at. e-a-e1-7o.uuu tti-oaua,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL:(OR REMOVAL) PERMIT
WI-This Permit can be signed only by the Local Registrar(Deputy or Subregiatrar)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 No F 601 Registered No._ ._
�„n�, BrrCll_.._.._ ateofD th rl._:-__l__.._I /
Town,Vil• � Y of C[I:�.._a..Is, �/ Age- 4/ Yrs. Color
1 ., sir,✓,L p (Or M )
•
(If city.,give street address
Cause of Death-
- yy_��-----__ _. _._
Place of Burial(,R..oval).. -. _..(L J
Cemetery.__..4 -"--- _..._._..__.. _. -- --• •- --Date of Burial..l %YfL__.L Ig�G.!
Certificate of Death of.___.._____.. ..&�& ..____--Sl._!_-:_.,, ., _ r._..._.__
(Give full name of deceased)
having been presented to me contai ng the above stated particulars and 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 my Local ecord with
the*be stated Register ,and on the basis the I EREBY A P
to. _.._. (N a of —#t `_e`"' __, _.__._ f
---e-y---.--... _ r 4. _.e.the•bod
_ 0r J
Dated--- U .!!/!a_..._.l.,a� �c�9 / ) (Signed)n :1t, //iv,' -,f� 0,-, wg
Local Registrar
Th Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the
State (subject to least cemetery or other regulations),unless removal is by common carrta►,in whirls case a
T.anai>Pa....i*NANw 641 to aaw..in..l
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Data of .- ._...I ituri
t or ion
in charge) wee.e.s
Iftr
(Qamaes,n
torium,etc.)
Parson in charge must return this Permit to Regfsteai of his District within
LLEVElt(7)DAYS from above date. If no person is in charge,the UNDER-
TAKER MUST SION ABOVE STATEMENT,write across the face of the Permit
the words"No person in charge,"end PILE PERMIT WITHIN THREE(a)
PATS 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 body. * • b The undertaker shalt
deliver the burial permit to the person in charge of the place of burial,before
iin or otherwise disposing;emit
�e when corpse o it�t,
withinwhereaccompany
aft f4 charge
of the place of burial.
f,330. Duties of undertakers; interment wig AO Mate. g the inter.
meat,or other disposition of the body is to be made withinthe slaw the word
ins of the burial or removal permit may,be limited to a statement by the
registrar,and over his signature that a satisfactory certificate of d ath,having
been filed with him.as required by law,permission is granted to Enter remove
or'dispose otherwise of the body,stating the name.ag.sex,cause ot,death
and ot r necessary details:upon the form prescribed by the commissioner of
} MI. 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 aliall endorse upon the permit,
the date of interment,or cremation over his signature,and than return all
permits so endorsed to the registrar of his district within seven bathesall interred
or otherwise disposed of on the premises under his charge," each case stating
the name of each deceased person,place of death, date curial or disposal
and name and address of the undertaker; which i�,,,l 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 muster? or burial grniiM
having no person in � shall sign the burial or removal permit giving
the date ofrbau�riieal,ands write across the face of the permit the words "No
theem n in registrar'of thethe iin burial
the c or emetery val permit within iliac days with
1�'SEITONS and UNDERTAKERS via the relat ve to the re-
at�sender are liable to a eft, of NOT FIVE DOLLARS
OR MORE THAN now DOLLARS POE FIRST OFFENSE. The
• lami��forced. Locals strars,are required,ender penalty,to report