Decker, Herman Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
yr 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. ��
/ ,� Villa-_
Dist. No`5( f County......1 i `:.�.-, o • „- ... c J
(If city, give street address)
Name of deceased AA/61,----12"2-1-4,'-- \1.... Veteran .��l�J
•��SS (If cteran give name of War)
"'�,�L• Single, married, widowed, 'Z,y7 u
Sex•, ... olor r divorced (write th word)........ Date of Death.... . 02 ...19... ..p
Age Yea s Mon s ... Days Birth ace
Cause of Death. ... .; ' Y ' 4r .dr„4.z.a424
Certificate was signed kr
M.D.
Address ... ,.
Place of Burial (or Removal)..
(If body is to be to potarily held as later) 2
Cemetery.... ... AA-4— Date of Burial 3..0ft 19...Y.
(If body is to e temporarily held,fill in space later) J
The Certificate of Death containing the above stated particulars, having been pres' ed to m , 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
Numbedand on th ha ' ereof HER Y GRANT A PERMIT
1. -3.4, 141914,e-r4_4230:AX"1.7-(14
ddress)
the . . . . .. to hold tempora ' d the body.
. . . .. ... . . .
( e or pe h ving cbarg corpse) (Inter,remove, e s ose of[state how])
Dated' E�C r 19.. 7 (Signed) .... L ,•
ocai lt'
This it i fficient 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.
f,
ENDORSEMENT OF SEXTO OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
,,,r CREMATIO ARk: [ADE
r.
Dateraf ����
,/.^' ( le
a 71:111"1192^-21—AL,'
(Signefl') t.:w, .. ..r .1�
(Person /1-C
in charge) ...
(Name of Cemetei , Crematorium, etc.)
Person in charge must return thie`iPermit to Registrar of his District within
SEVEN (7) DAYS from above date. *If no person is in charge, the UNDER-
TAKER MUST SIGN ABOVE STATEh()rNT, write across the face of the Permit
the words "No person in charge," and FILE PERMIT WITHIN THREE (3)
DAYS with Registrar of District sn 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 whi:h shall be found dead therein shall not be
interred, deposited in a vault a tomb, creniated or otherwise disposed of or removed
from or into any registration.iistricf,or be teipporarily held pending further disposition
more than seventy-two hours after death Lin,' is a permit for burial, removal, or other
disposition thereof shall have been prober;issued by the registrar of vital statistics of
the registration district in which ti r. death "a-cut-red or the body was found. No such
•burial or removal permit shall Ise issued by a.*.registrar until, wherever practicable, a
complete and.satisfactory certificate of death 11 s been filed with him as heretofore pro-
vided; provided that when a dead body is tt� l'ported from outside of the state into a
registration district in this state for burial, a transit or removal permit issued in
accordance with the law and health regukatio of the place where the death occurred
shall he given the same force and effect as t burial permit herein provided for. No
.-registr_ar-efa�,t statiet es.slaatt.receivefa, v£ `ior the_issuaptce of burial or removal
permits under this act other than the compensation provided-VW-article.* 'Prb'6ided,
however, that the commissioner of health shall have power tot''prpmulgate 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,jemoval 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 ofciat 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 h41
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 clays with the registrar of the district in which the cemetery is located.
vir 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.