Shepard, Melvin Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
yr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTWI( E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town e • red
.. 1(//
Villa•e
Dist. No�+�/f!,1...County. o
4? .
O (If city, give street address)
Name of dece ed .. / . ,.... .. ��.... "/ Veteran
' gle, married, wido ,, / es+ (IfOn. give nNernr)/�
. or.. divorced (write word)... .. .. "21. ' .Date o .di ' ..... G..,(/f��....197..2
Age r..7Ye�... •.Months / .........Days / irth.lace - .
Cause of Death.. . .. i - - / -
Certificate was s? • •r ..+ ,4-"„- 4- ,... M.D.
Addres :. :"'r•� . ' �r,, •
Place of Burial (or ;#, •val • / ,... -.� , ... ... . .. `i •
(If body Is to be tem.or- �eld •1 "#.• / f ��//�
Cemetery ./..•.... " .' ' Date of Burial ./. • 07, 19'Y.
(If body is t. .- ...rarity held,fi space later)
The.Certificate of Death y taining the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, ave recorded it in my Local Record wi . the above ted Registered
Num the basis I''HE `:Y GRANT A PERMIT it
rd.'
the , / /1 / i °)
'� to hold temporaril�//�1g'(�/ .� body.
(Undertak: • • raon ha •_ charg se) ii/fir• 400,
..
Dated . ..• 19.` (Signed) `
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ject to local
cemetery tar either rwvuletinnal_unless remnneil la by nnmmn,,watvitr_ :.. ...1,L.1, ...... . T.....i• P.......l• /VQ %L. R91 :. ....i.,..1.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
�Date of....._._. ACt'�4,-.Sr.../
(Intermen r cr e?;n) .
(Signed)
(Perron
in charge)
(Name Cemetery, 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
§ 375. Permits for burial or removal of dead bodies. The body of any person
whose death occurs in this state or which shall be found dead therein shall not be
interred, deposited in a vault or tomb, cremated or otherwise disposed of or removed
from or into any registration district,or be temporarily held pending further disposition
more than seventy-two hours after death unless a permit for burial, removal, or other
disposition thereof shall have been properly issued by the registrar of vital statistics of
the registration district in which the death occurred or the body was found. No such
burial or removal permit shall be issued by any registrar until, wherever practicable, a
complete and satisfactory certificate of death has been filed with him as heretofore pro-
vided; provided that when a dead body is transported from outside of the state into a
registration district in this state for burial, the transit or removal permit issued in
accordance with the law and health regulations of the place where the death occurred
shall be given the same force and effect as the burial permit herein provided for. No
registrar of vital statistics shall receive any fee for the issuance of burial or removal
permits under this act other than the compensation provided in this article.* Provided,
however, that the commissioner of health shall have power to promulgate rules with
reference to the removal of bodies of persons whose deaths occur on trains, boats or
other carriers engaged in the transportation of persons within this state. (Am'd by
L. 1932, ch.267.)
•See section 390.
§ 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. ***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 trans-
portation 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.
§ 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 hit
signature,and shall return all permits so endorsed to the registrar of his district withir
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 inspec-
tion; 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 buria
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 withir
three days with the registrar of the district in which the cemetery is located.
to'SEXTONS and UNDERTAKERS violating the law relative to the return of
permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORI
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced