Kingsley, Ella Form VS:e NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 Register No -?
/
Dist. No 670 U 'Count Village
or City
..... .. .. . . .... . . 1
(If city,give street address)
Name of ceased.... Veteran
Single, marri , widow (If ve cyan. •ve name of War)
g r i3 f�
Sex Color... . or divorced (write the rd) ... . . . . ate of ath..e„7`„Atr:G� ,��r.•�• 19
Age 4. Year ..,..Monk22f
/. .....Days irthplace.. i
.. . . .. ..
Cause of eath...... .. .... . •.•.
Certificate was s' ed • M.D.
Address . ..Place of Burial or emova111(If body is to be rarity held in space
Cemetery .... Date of Bu ,l7 19.
(II body Is to be emporarily held,All In space let
The.Certificate of Death containing 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 regis ion, have recorded it in my Local Record with /�ab�ovestated Registered
Num. a . on th b. is . • EREBY GRANT A PERMIT
to 4l ' . j G
the I �.(. ' /
....to hold temporarily and dress) ,,.. the body.
rndertake or person having charge o! o se) n r, or o dispose of(eta how])
Dated' .2.:.../.to 19...14 (Signed)
•Local Beglrtrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (anbject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
INDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
•
CRE ANIONS ARE MA E•
Date of r y ../7 19..7�
Interment
(Signed) '. ... .. ... ..
(Person ,�"r c�JA
is char �y ems.,(.. (Name ato e
(Name of Cemetery, Crematonu , e c.)
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 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.
sue'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.
•- Form VS 67.
NEW YORK
STATE DEPARTMENT OF HEALTH s
ALBANY
UNDERTAKER ' S REQUEST TO DISINTER BODY
See Special Administrative Regulation 1, subdivision 4, Relating to the Trans-
portation of Dead bodies by Common Carriers, as printed on the back of TRANSIT
LABEL.
N. B. Permission for disinterment must ALWAYS be obtained whether the Body
disinterred is to be transported by Common Carrier or by other means.
I HEREBY REQUEST PERMISSION TO DISINTER the dead body of
M.r.s....Ella..K.ingsl.ey , who died in the* City
(City, Village, Town)
of Glens• Falls on*. Feb..,..1.5,. .194.9 , Sex Female.,
Color or race* White , Age* 68 years, and Cause of Death*....Car.d.i.ac
.d.e.c.ompen.sa.t;on NOW INTERRED IN Pine V1,.ew Cemetery Vault
(a) The body is to be TRANSPORTED BY COMMON CARRIER for
at
(State fully the disposition to be made of body) (Name of place or cemetery)
(b) The body is NOT to be transported by Common Carrier but is to be transported by
motor...hearse•-.for••buriaal Gl ,..s..., ,,. . ,: : -ry
(State fully the disposition to be made of body) ' 'Fr,, o e or cemetery
(Signature of undertaker) -
Dated April 27th., 19.49... Address 341 G P• t, ,...Gl.en.s.. .a11,s, N.Y.
License No...4493
APPROVAL OF HEALTH OFFICER
Dist. No.
I HEREBY APPROVE above Request and r ommend that Permission be granted.
(Signature of Health Officer) . .. .
•
HEALTH FFICER —4ueer.sw , ,Y.
•
Dated -Z7 19.��
.r"- Instructions to Local Registrar: Fill out (a) Transit Permit for bodies trans-
ported by Common Carrier or (b) ordinary Offical Burial (or Removal) Permit for bodies
not to be so transported, in each case writing the word"DISINTERMENT"on the Permit.
The data required concerning the decedent may be filled in from the local register or
cemetery record. When data can not be obtained write "Unknown" in spaces in-
dicated by (*).
The Disinterment blank should be filed and carefully preserved in your office.