Cleveland, Christine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rgr 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 aril acceptance of a CORRECT AND COMPLETE CERTIFICATE
OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. Registered No.
Town,
County, Village ' ''e r...E4.11S., Ni. YY
Or City /J n (If city, give stye address)
Name of eceased
/j�/ Single, married, widowed,
Sex . Color �r or divorced (write the word)
Date of Death -,G / 19...4. �
Age 7 V Ye
Moths /a D s _ 'rt la .. . .
Cause of Death p, .(� �
Certificate was si b s... .... .. ..... ...:...
M. D.
Address • .. f. i.. .. .
Place of Bur' (or Remova ) - • .
(If body is to b e porarily�held, 1 in�s�Sace er)
Cemetery... -� Date of Burial 7 6 19... 3
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, 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 statedteed_Registered
Number,
d_�,� %C/ e baa}s they f I EREBY GRANT A FERMIT S.%��%� /
ciy
•
(Address)
the.. . to hold temporarily d th744
y.
taker or pe h ug char a of corpse) (Inte ikmovey r ise dis e of [state how]).
Dated /� 19. 3 (Signed) ((jj�t
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a bo to any part of the State (subject to local ceme-
tery or other regulations),unless removal is by common carrier, in which cas a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
C MATIONS ARE MADE
Date of � , �P 19J$3
(Interme cremation)
(Signed) `- —
(Person
in charge)
(Name of Cemetery, Crematorium, etc.)
Person in ch ge ust return this Permit to Registrar of his District within
SEVEN (7) DA 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 dispo-
sition 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 provided; 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 o: removal permits alder 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 trans-
portation of persons within this state. (Arri'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 dispo-
sition 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 transportation 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.
§ 380. Duties of undertakers; interment within the state. If the interment, or
other disposition of the body is to be made within the state, the wording of the burial
or removal permit may be limited to a statement by the registrar, and over his
signature, that a satisfactory certificate of death, having been filed with him, as
required by law, permission is granted to inter, remove or dispose otherwise of the
body, stating the name, age, sex, cause of death, and other necessary details upon the
form prescribed by the commissioner of health.
§ 381. Interments. No person in charge of any premises on which interments
or cremations are made shall inter or permit the internment 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 premise
under his charge, in each case stating the name of each deceased person, place ,y c
death, date of burial or disposal, and name and address of the undertaker;
record shall at all times be open to official inspection; provided that the unit b
or person having charge of the corpse, when burying a body in a cer
burial ground having no person in charge, shall sign the burial or remr
giving the date of burial, and shall write across the face of the pert,- cram
No person in charge," and file the burial or removal permit within \
the re,gistrar of the district in which the cemetery is located.
13,'SEXTONS and UNDERTAKERS violating the law re
turn of permits are liable to a penalty of NOT LESS THAN FI`/
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST Ob.
law will be enforced. ..Local Registrars, are required, under penalty, to