Gifford, Jesse Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town gistered No.
Witrge
Dist. No�.�Q.47.County sigh--'t or-City
/J (If city, give stree dress)
Name of deceased �/ �►/ Veteran
ngle, married, wido �r (If v teran, • e ham of War)
Sexf,. Color.. or divorced (write the,{- word) Date of Death. ... . .. . 19.. ..?
Age l Years / M-.�, s.d...«...Da Birthplace / r •• •• •
Cause of Death
Certificate was signed by /. .t . .. M.D.
Address kg.lee4
..ch.•e ►
Place of Burial (or R oval) — z�d�
(If body is to b ri Id, 11 s ace later)
Cemetery .i Date of Burial. a 19.q.7
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated partic lars, having been presented t me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY A REQUIRED BY LAW,
I have cepted the same for registration, have recorded it in my Lo 1 Record with the above stated Registered
Num and on the b sAliweof pgpiR Y GRANT A PERMIT 3-r1A- ',.--
/"
) (Address)
the ;[,.4 to hold temporaril an the body.
ndertake r person having charge of orpse) n ove,or oth w se dispose of[state how])
Dated: . / Q 19..t.If...7 (Sign r ..
Local Registrar
Permit ' sufficient for the Removal (and Interme emat, of a body to any part of the State (subject to local
........1..... ... ..el.n r.e..1.1:..n.1 "'otiose row.nr,nl 1. I.,nnrwsnnw e.nrei _ .n irk rasa a Transit Permit (VS No. 62) is reauired.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
CREMA IONS ARE MADE
Date of _. .... It -- 1 ..
terme aeon)
(Signed) ire
(Person
in charge)
(Name of Cemetery Crematorium, etc.)
Person in charge must return this Permit to Registrar of his District within
SEVEN (7) DAYS from above date. ff 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 wi' him as heretofore pro-
vided; provided that when a dead body is transported fro • ou ide of the state into a
registration district in this state for burial, the trans' or 4111, val permit issued in
accordance with the law and health regulations of e MP r. the death occurred
shall be given the same force and effect asthe . r 1 140,
terein trovided for. No
registrar of vital statistics shall receive any e uance of rial or removal
permits under this act other than the corn is vided in this art le.* Provided,
however, that the commissioner of h • th to ve power n promul+, to rules with
reference to the removal of bodies •f whose de ccur on 'ns, boats or
other carriers engaged in the tr'n tin of person�ss in thi�. (Am'd by
L. 1932,ch.267.) �i
•See section 390. N.
§ 379. Duties of undertake In each4rthe u on having
charge of the corpse,shall file the cer cafe of d''eath wi k rat the district in
which the death occurred and obtain a urial or re v' - i,. t ' to any disposition
of the body.***The undertaker shall liver thtirrr - • o the person in charge
of the place of burial, before interring tic o hhtitt• t 'ing of the body; or shall
attach the removal permit to the box contaili e, when shipped by any trans-
portation company; said permit to accompatt t •rpse to its destination, where if
within the state of New York, it shall be deli -• 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 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 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 burial
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 within
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 MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced.
Local Registrars, are required, under penalty, to report violations thereof.