Laraux, Malonina rorm V a i.o.oa. o-a-oa-....v.... .•-.wv...
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lice This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)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 5"... ®/ Register N
n
County W,- Date of Death ? Ig�7 Z'
i1- - '"Q-* Yam'' •Sex.- Xge 2 3 s. of. ��A Lu4J •
-
lage ar City- • (Or Mos.)
(If city,give street address). •
Cause of Death _
Place of Burial(or e o al _: t • ..
Cemetery .-___-� _._. _._ `sly Date of Burial 9---
Certificate of Death of t
(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, I have accepted the same for registration,have recorded it in my Local Record with
the above stated Registered Num r nd on the basis they f I HEREBY GRANT A PE IT
to N me o u dertak ress)
•
the ,
(Unde er or son having charge ocopse) (Int emove,or hther!c "/`/.e of[
Dated l� I.9_ G-- (Signed) •
Local Registrar
This ermit is flicient for the Removal (and Interment or Cremation) of a body to any part of the
State (subject to Ioc cemetery or other regulations), unless removal is by common carrier,in which case a
'rrnnsit Parrnit(VS Nn.E91 in ra.nu,rnd
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREM TIONS ARE MADE
Date of
(In rmen cr on)
(Signed).___ _ ^•
(Person AS
in charge) (Name o�Ce cery,Crematoria tc.)
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
379. Duties of undertaker. Iq 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. • • o The undertaker shall
deliver the burial permit,to the person,(red
of the place of burial, before
interring or otherwise disposing of t e body; or shall attach the removal
permit to the box containing the core e,when shipped by any transportation
company; said permit to ac erup a corpse to its destination, where if
within the state of New York,it be delivered to the person in charge
of the place of burial.
§380. Duties of undertakers; interment within the state. If the inter-
ment,or other disposition of the body's to be made within the state,the word-
ing.of the burial or removal permit nay be limited to a statement by the
registrar,and over his signature that a satisfactory certificate of death,having
been fled with him,as required by last,permission is granted to inter,remove-
or dispose otherwise of the body,statilag the name,age,sex,cause of death
and other necessary details upon the firm prescribed by the commissioner of
health.
§ 381. Interments. No person 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. Stil.h person shall endorse upon the permit,
the date of interment,or cremation 'his
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 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 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.
S SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
lain will be enforced. Local Registrars,are required,under penalty,to report
violations thereof.