Carson, Herbert r man va PIO.el. e-a-oa-lv.uvu µ.-ammo/
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tta-This Permit can be
signed or only by the Local Registrar(Deputy or Subre istrar)of the pPr�Primary Registra.
RE CT AND COMPLETE CERTIFICATE FICAT)inEOFhich EATH, LEGIBLY WRITTENe death o-Awrred after the IN DU and URABLE BLACK INK.of a COR-
RECT sl
Dist No..._---:-r.._•---------_-, R •
ed .__. .....» __.. ___
County_ - arse ..-•-••---_- Date of Deat1 � - __..._--$g_q>.
Town,l it tty of Glens Fails SeL Age- - -.Yrs. Color
lage,or City- - _. ._..... ...__..__ ..
(If city.give'atreetaddress) (Or Mos.)
Cause of teeth ___.»--- . X�
Place of Burial emoval)-— '/ ..i_.__
Cemetery.— _ _ -» ____________f,s_ .___._...__._______Date of BuriaLati.-__6_-_Ig•>3..1
Certificate of Death of » _.._- .
(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, ve accepted • same for registration,have recorded it in my Local Record with
the a•0 sta• • -gis -• Number,and on the basis th-•, , ,,# �Za A PERMIT
the_ amr _-- __ -_._._..to_ may.. _the body.
yr r -having charge ctpae) (Inter / ,/ /ir 1 if
fk 'i_-___
- - — Local Registrar,
arm► Permit is sufficient for the Removal(and Interment or Cremation)of a body to any of the
State ( ject to local cemetery or other regulations),atniaas removal is by common camp.in which case a
Tea<ndt Pima r N4 ilr.a_MI ia ra..nir d_ -
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of 40 ti 4, -re
cremaMissed)
t ems).0_ (tame Cemetery' rematoiium,etc.) f
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
TAXER MUST SIGN:ABOVE STATEMENT.write across the face of the Permit
the words"No person in charge,'and FILE PERMIT WITHIN THREE(3)
MAYS 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. e * o 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,whoa shipped by any tra. tion
withincompan the said
eofof New t000rk it asnhall be delivererpse d its hhe pepes�son in chew
of the place of burial.
EEO. Duties of undertaM,; 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.having
been Sled 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.
tsi. Interments. No person j in inter
of any premises on which
interments or cremations are made shall inter or p t the interment or other
transitdisposippeern�it,any bogy
provides is
persona shby all dorseeuupon permitl,cremation s
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 disp of on the premises under his charge,in erroh case stating
the name of each deceased person place of death, date Of or dispr
and name and address of the undertaker; which record shall 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 cemetery or burial ground
having no person in charge,shall sign the burial or removal permit giving
the date of burial,and shall write awes the face of the permit the words "No
on in and file the burial or removal permit within three days with
person
or the district in which the cemetery is located.
1111"SEXTONS and UNDERTAUERS viola igg the law relative to the re-
turn of y�is are liable to a ttyy o ES�f NOT THAN FIFE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE." The
tam will S.enforced. Local Registrars,are required.under penalty,to report
violations thereof.