Hersey, Nellie r flw♦p aw.US. o-rortu.vw ,,.-awv,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
#?This Permit can be signed only by the Local Registrars(Deputy or Subbr�.g�trar)of the Primary Registra-
tion District(Town Village,or City)in which the death ace rred after the FILING and acceptance of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.. !f f Regis ed No }
County .. _.- ___ � Date of Death-.- .7_..._...Ig -
Town,Vil- :bG„L..GI.tR._..t2g f':�tf___-
lage,or City-- - -.. ___� Age orCa3 Yrs. Color_ _._
(If city,give street address) (Or Mos)
Cause of Death. ,e ._. __
Piave of Burial_(or Removal)--. ..- %�� _......----------...-..-.-----__._...__.._____-•---.__ ... ._
Cemetery .71
Sldfdr-!!1t Date of Burin
Certificate of Death of. ..�!_ ea_ 1.JIe.o .•-a,! .. _._._ ...:..:
(give full name of deceased)
having been presented to me containing the above stated particulars , after careful examination `
the same appearing to be COMPLETE, CORRECT, AND SATISIiACTORY ASREQUIRED B t
LAW,1I have accepted the same for restration,have recorded it in my Localecord :
tie stated ad Number,and on the basis th I HEREBY GRANT A P
hp ..a j--- —--� - .
sss;jail ( sa
e
(U :or person hving charge of corpse) w_
Dated _.._19of�,..ESigneSi)- - M ,
`is Permit is sufficient for the Removal (and Intl or Crematie)of.carriier t k
""'*Rite (subject to local cemetery or other regulations),Wail*ransasal is by common ,in :
Transit Permit(VS No.62)is reauired. i. �,>-
ENDORSEMENT OF SEXTON..OR pitteorr IN
CHARGE OF PREMISES ON WHICH"'i' TER-
• M' TS OR CREMATIONS ARE *ADE
Date of ' _. _:--....,.....i¢...r..
(Interment or cremation) » m
(Person -
in charge)...:.._.--.... »..» ». _
(Name of Cemetery,Crematorium,etc.).
Person in charge must return this Permit to Registrar of his District within
SEVEN(q)DAYS from above date. If no person is in charge,the UNDER-
TAKER MUST SIGN ABOVE STATEMENT,write across the lane[the Permit
the words"No person in charge,"and FILE PERMIT wrnartTHREE(3)
SAYS with Registrar of District in which cemetery is located.
EXTRACTS OF THE VITAL STATISTICS LAW
1379..Duties of undertaker. In each case the undertaker' to person
having charge of the corpse,shall file the certificate of death with the registrar
of the district in which the death occurred end obtain a burial or removal
permit prior to any disposition of the body. • • o The dell
deliver the burial permit to the person in ch
arge of the ll attach of� htal,removalbody;
permit to the box con ,p y,
j
nste permittti a r ,�,; C ,
thewitbin state of New York,it shall be delivered to the penes In charge
of the place of burial. ,
¢330. Duties of undertakers; interment wihitt► the state, If` Inter.
went,or other disposition of the body is to within the s ate, wort
ing o the burial or removal permit may be limited to a statement by the
registrar,and over his signature that a satisfactory certificate.of death,baying�
been filed with him,as required by law,permission is to intectratoogat
or dispose otherwise of the body,stating the name.age,sex.cause of death
annd other necessary details upon the form prescribed by the commissioner of
i fifi.'.,Interment...No person I�ny charge of any prey on which
intermentsor cremations are made shall inter or *other
disposition of any body unless it is accom ' ` by a burial. Lion Cr
thtratt,as herein provided. Such person shall endorse upon
t interment,or cremation ester his•signature;,grid return
to the regiekar of district .`
or• otherwise of on the - .
the name' f eac�ceased peso place of death,add or'
and name and address of the undertaker; which at all times >:.
open to official inspection; provided that the or.:
charge el the: corpsie,when burying a bod ia` u'
having no person in charge,shall sign the or" t
the dataof burial,and sh.11 write across,theface of't `,
person in charge and file the burial on removal ,flays i;
the registrar of the district in which the cemeteryp '
SEXTONS and UNDERTASEgS vio turn permits are liable to a Sean__1tyeet NO , ',r fi
NOR MORE THAN PIETY DO PO
N1ss rill esthete forced. Local Registrars)are }