Lamue, Aura Form v&si NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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 /Registered No.
ll
Va
Dist. No , County or1Citpe ! ? i r„t-,"z. "" 4Z// '"`
(If city,give street aress)
Name of deceased Veteran /{
((f veteran, give name of w.�>
Single, married, widowed,
Sex Color or divorced (write the word) Date of Death....:;' .1.. , 19
Age Years Months-.., „//...D.ajs Birthplace e....(da...
Cause of Death ;:.ir, ;;
Certificate was signed by M.D.
Address
Place of Burial (or Removal) LI•
f
(If body is to be temporarilyfisid,flU in space later) _)
Cemetery =%.:'' - " 2 Date of Burial /'2 ,27 19
(If body is to be temporarily held,fill in apace later)
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 registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to
(Name) (Address)
the to hold temporarily and ".,7,...,., e body.
(Undertaker or peruse yying charge of corpse) (Inter, remove,or otherwise disnose of [state how])
Dated .�" 19 (Signed) .L.�..x.,.c ti�1r� 1 f..,
.L6cei Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
rev.VLSI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Par can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
DEATH,o _City m which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
y MITTEN IN DURABLE BLACK INK. Town Registered No._ ._..__....._._
Dist. NoJ1sA,G1.County.L4.C'tY.t.tts�':Sts,. ... ............... or C No—
Village Lei..'.. -,-, ,:c:EY.// {.l..
Y• (If city, give street reae)
Name of delea&ed ;.,2.-(...,f...(... ,u.:r. :.: . .&. Veteran
,,. Single, married, widowed, (If teleran, give name of War)
Sex i 7 Color ..LL.l or divorced (write the word) Date of Death. 2 .�,.� 19`
.. Years -"la-Months. D
Age
+ r. f , Birthplace ;: .,�..c ..6c,,..
Cause of Death 4: ., ... :s z�_!
Certificate was-,signed by4.- M.D.
Address. ' -'. ,+z, � :z—.�z L. c-r ,
Place of Burial (o Removal) ,2/'..�G ' '—I. � .0 ,) , .
(If body Is to bertemDorarily h Id Il pa space later)
Cemetery, lz.e.s.-.,,1.g.:L.�J--"" Date of Burial.. 2J
,,..... .* ,27 19".`",.
(If body L to be tempo wily held,'1111 In space later)
Thu Certificate oUeath 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 registration, have recorded it in my Local Record wi h the above s ted Registered
Numfr the basis thereof I HEREBY GRANT A PERMI __ . ' _ Z!
to ,..a •c,,-c....x W - �:' 3rQ..tc..c...: li-the (N / (Address.�• :.-:�. ,. ..to hold temporarily and.... e,�,.�, klle body.
or pe �s trig charge of corpse) ,/ (Inter,remove,or-otherwise 4 IUose of[slats bow])
Dated .Z.. �- I 19 f (Signed) �• :.G�„c...( f� ;,4. .1"Wit/ ` `.. -t.,/
/ • Local Registrar
This Permit is sufficient for the Removal (and Interment or emation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of _ 7 19 ....
(In t cremation)
(Signed) TnekTV"1"4.-4--)
(Person
in charge) .,4254firt.,. 474.8.314
(Name of metery, Crematorium, etc.)
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 VIAL STATISTICS LAW
§ 375. Permits for burial or removal of dead bodies. The body of any person
v•hose 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; * 41.When a dead body is transported from outside of the state into a
.re.istration district in this state for b ri I, the transit or removal ,e it I
, • same fate a • e c burial permit herein provided for., No
r strar = Aral statistics shall receive • fee for the issuance of burial or removal
permits under this act other than the corn 1-ation provided in this article.* Provided,
however, that the commissioner of health all have power to promulgate rules with
reference to the removal of bodies of pe'.; whose.deaths occur on trains, boats or
other carriers engaged in the transportati ; of persons within this state,
•See section 390.
§ 379. Duties of undertaker. In ease the undertaker, or person having
cha.ge of the corpse,shall file the certificate death with the registrar of the district in
which the death occurred and obtain a bur" 1.0r removal permit prior to any disposition
of the body.*••The undertaker shall deli `,r the burial permit to the person in charge
of the place of burial, before interring 0,0•,‘ herwise disposing of the body; or shall
attach the removal permit to the box conta g the corpse, when shipped by any trans-
portation company; said permit to account," the corpse to its destination, where if
within the state of New York,it shall be de red to the person in charge of the place
of burial.
§381. Interments. No person in ch o 'remises on which interments or
cremations are made shall inter or permit th. •-„
unless it is accompanied by a burial, crema 4t*titi• • n14',"*.'"4
Such person shall endorse upon the permit,t date of interment,or cremation°air Inti4
signature,and shall return all permits so enti,', , to the registrar of his district *thin
seven days from the date of interment or cr ion. He shall keep a rgeord of all bodies
interred or otherwise disposed of on the pr es under his charge,in each case stating
the name of each deceased person, place of • th,date of burial or disposal,and name
and address of the undertaker; which record all at all times be open to official inspec-
tion;provided that the undertaker or pets' "ving charge of the corpse,when burying
a body in a cemetery or burial ground havi : o person in charge,shall sign the burial
or removal permit, giving the date of bur ,„ and shall wriftftcross the face of the
permit the words "No person in charge," a ,file the burial or removal permit within
,
three days with the registrar of the district i, hich the cemetery is located.
SEXTONS and UNDERTAK ' ' g the law relative to the return of
permits are liable to a penalty of NOT " AN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE Fl -1 a 7 ENSE. The law will be enforced.