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Cullen, Nathalie Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tz 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._2. ' L • Dist. No$.4rI /O. ' .. t_. . .,. Village Q ..County or City ... � .. .. .... ty, give street address) Name of deceased'' an t iF v an, give name of War) Single, married, widowed, Sex...2.3 Color 1"1-4 or divorced (write the word) ate of Death.. / 49 9..1fr Age 4 f Years. a Mon s /a►17... ays� iBirthplace.... Cause of Death.., i Certificate was signed by M.D. Address r _ Place of Burial (or Re val) ,t r (If body 1a to be temp orari] eld 11 1n 1 i, Cemetery • Date of Buria r 19 (If body is to be temporarily held,fill in space 1 'r) Mg Certificate of Death containin the above stated particulars, having been presented to me, after careful exami- iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, [ have accepted the same for registration, have recorded it in my Local Record with the above stated Registered Slum o th b s. f I- R B RANT A PER MI - o • r ms he to hold temporarily d the body. ( erta or person having charge y pse) (Inter, r o or o dlsoose of(state ]) Dated... ./ 19.. (Signed) Deal R Pe is sufficient for the Removal (and Interment or Cremation) of a body to any part o the State (subject to local :emetery 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 M E Date of _ ...._.._ .... _ • ............ .. 19 .Z ? (162.4" nterent ere on) (Signed) r m (Person in charge) g ) (Name of Cemetery, Cremator t, etc.) �M Person in charge must return this Permit tC 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 an) 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; * * ' *.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. •See sect,on 390. § 379. Duties of undertaker. In each case the undertaker, or person having cha,ge 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 Dyer 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. Ile 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. SEXTONS and UNDERTAKERS violating the law relative to the return of permits are liable to a penalty of NOT CMS 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.