Suprenant, Rolland '/ c roan VS01. 11-Z1•5i-)0,UUY (17.31Y4)
•=4 NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
Dist. No ,,,,1�....Lw , 7 Registered No ?"
Town, `�` ..�� ,e� o1
County... ... Village
or City (If city, give street address)
Name of deceased .... .
Single,married, dowed
Sex%�! Col or , ,
or divorced (write the word).... .. . . . Date of Death / 19 3 4
Age ' f..0 Years 3 Months. Days Birthplace (F t
Cause of Death � ' �,�� .. f�- ��
Certificate was signed byG ��4 c-�f ... A _ M. D.
Address «�".���Z �' , ..
, , „i,-
Place of Burial (or Removal .. .. .
(If body is to bet arily he fi ' s e later)
Cemetery. .... Date of Burial '0-'%'y .2— 2 19 3.7d
(If body is to be temporarily held,. I in space later)
The Certificate of Deat 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 stated Registered Number,
and on e basis thereof I EREBY GRANT A PERMIT i/
( ) (Address)
the to hold temporarily and the body.
(U dertaker o person having charge of core) (Intl r ..Se; o otherwise ' pose of [state how]).
Dated.......4�� -/ 19., (Signed) p.! . .e.".7
Local 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
5:11^, LY/ �r 19
Date of t.,,' i t,:. '..r
/��1 P (Interment or grematiott)
(Signed) �A..'`✓ , Q, } s i
(Person
in charge) " ' "•,,.> +
(Name of Cemetery, Crematorium, etc.)
Person in charge must return this Permit to Registrar of his Dis within SEVEN
(7) DAYS from above date. If no person is in charge, the UNDE 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 or removal permits under this act other than the compensation
:`.; vided in this article.* Provided, however, that the commissioner of health
.t_.promulgate rules with reference to the removal of,bodies of
, persons Who-se.deat s occur oii'trai s or,orlier, carriers engaged in tlhr--ua�: ''
portation of persons within this state. (A d by L. 1932,ch.267.)
"See section 390.
§ 379. Duties of undertaker. In h case the undertaker, oit person having
charge of the corpse, shall file the certifi e of death with the registrar of the district
in which the death occurred and obtain tikburial or removal permit prior to any dis-
position of the body. * * * The undertaker shall deliver the burial permit tc 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; ,aid 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 madts 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 ',f 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 hea:tli.
§ 381. Interments. No person in cha age 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 shad 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'tname 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!inspection; provided that the undertaker
or person having charge of the corpse, yvhen 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 cross the face of the permit the words
"No person in charge," and file the burial r removal permit within three clays with
the registrar of the district in which the cemtery is located.
lir 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.