LaPoint, Baby Boy NEW Y)RK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mor This Permit can be signed or by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death warred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DRABLE BLACK INK.
Dist. No.`f
Registered No
County ' ��-R- 0, c Village
7y ,.. .......
V ._...
-er'Erty (If city, give street addres/
Name of deceased ' " �� -n ,
Sex -K Sin ,married,widowed, s.f
Color vorced (write the word) Date f eat 19
Age Years... Months Days Birthplace .7".ie c
Cause of Death....-....... -c z,' %
R.Certificate was signed �` ta. ....M. D.
Address Ga� " '—u-c4 -
t
Place of Burial (or Removal) ./
(If body is to be tsprarily eld fi1Lin spaa later) _ /
�D�'� ! ! �.s 19'
Cemetery �t2-emu-✓ ate of Burial
(If body is to be temporarily eld, fill in span later)
The Certificate of Death containirg 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 the sis ther,o I•HEREBY GRANT A PERMIT v/
"�_�yllame) (Address)
the..........._...........
' °cam" _ .. _._ ..._...._. ...............to hold temporarily and
�- _ ..-_.._.....the body.
(Undert or person'wing pparge 4 corpsr) Inter, remove,�,ik other dispose of [state how)).
Dated.._.. ............: -' 19 (Signed) _.. . °�.. . �
Local Registrar
This ermit 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 Or
PREMISES ON WHIR INTERMENTS OR
CREMATION ARE MADc ""'� _
Date of 2 s - 19`/
(Signed) (Interment it, = _
(Person `
in charge) r; 4. ::.:....... . i
(Name of Cemetery Crem tyre t, etc.)
Person in charge must return this Pe t to Registrar of his District within SEVEN
(7) DAYS from above date. If no perso is in charge, the UNDERTAKER MUST
SIGN ABOVE STATEMENT, write acr s 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, crenated or otherwise disposed of or removed
from or into any registration district, or 5e 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
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.'i(Aun 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 dis-
position of the body. * * * The undertaker shall deliver the burial permit to the
person in charge of the place of burial, iefore 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 Nejw York, it shall be delivered to the person
' ,in charge of the plaee'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 beet% tiViherwise of the
required by law, permission is granted to int r e --
body, stating the name, age, sex, cause ..t Alan'', and other necessary details upon the
form prescribed by the commissioner of heath.
§ 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 unlqp if ; r,n-;;:hied isp s4 burial, cremation or transit permit, as
Ft herein provided. Such person shall endorr�'t upon the permit, the date of interment,
or,cremation over his signature, and shlill return ag 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 interrel.or otherwise disposed of on the premises
under his charge, in each case stating th1 name of each deceased person, place of
death, date of burial or disposal, and na4e, and address of the undertaker; which
record shall at all times be open to office , inspection; 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.
Mr SEXTONS and UNDERTAKERS violating the law relative to the return of
ermits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
AN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced.
ocal Registrars, are required, under penalty, to report violations thereof.