Fielding, Frank rorm va NO.01. 3-0-33-3U,UVU t1/-Ju/Z)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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,H� L GSI�BJLY WRITTEN IN DURABLE BLACK INK.
Dist. No.C.l...6 / ( Registered No.
J Town, -
County fit/ V 14 g
(If city, �i street address)
Name of deceased .. .....
Single, married, widowed,
Sex Color or divorced (write the word7/`4
�fj/
` Date of D at S �--- 1.Q 19..3
Age .. ... Years 6 1 Months Ai - Days Birthplace � C 4-ee- ,.�_.. � ��/ _.-
•
Cause of Death �d... . .... ..... ... .. 4�.
Certificate was_sIgn�d ,.... ••�,(•, t .,.,.,� `'.�,��.........:.�:......... ................._.. ,.... �-
Address �7 'T4 0..... ... ...
Play of Burial (or Removal) !� .�-�—.
ey
(If - y ig to s� temporarily held 1 in�a later)
C .f:� -v^ .. .. E... / Date of Burial / 19.. .. '
(If body is to be temporarily held, fill in space ter
The Certificate of Death containi 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
Numb r, and on the b cis th HER BY GRANT A PERMIT - ,
to t -%l V ��� , C� ,
the 1�^w (N me) 1 ( ss)
- "\ `�'✓L/e--4-4--) to hold temporaril and.,�2�r' ,. . r.. the body.
ndertaker or perspn having charg of:corpse) (Int re ve, r of dispose of [state how]).
Dated G^'�. ....1 19 3 (Signed)rx-�/.....s........ E- . .
. Local Registrar
his Permit is sufficient for the Removal (and Interment or Cremation` of a dy to any part of the State (subject to local
tery or other regulations),unless removal is by common carrier, in which case a i ransit Permit (VS No. 62) is required
ENDORSEMENT OF SEXTO OR PERSON IN CHARGE OF
PREMISES ON WH H INTERMENTS OR
CREMATIO S ARE MADE - '/
Date of......., ..... l 19r3
I m nt r crema' n
e —
(Sigr
(Person . - ;...:
in charge) m, ec.)(Name of Ceme Cr ator a c.)Person in charge must return th it to Registrar of his District witn
SEVEN (7) DAYS from above date. f no person is in charge, the UNDER-
TAKER MUST SIGN ABOVE STAT ENT,write across the face of the Permit
the words "No person in charge,' and ILE PERMIT WITHIN THREE (3)
DAYS with Registrar of District in whic cemetery is located.
EXTRACTS OF THE V TAL STATISTICS LAW
§ 375. Permits for burial or remov of dead bodies. The body of any person
whose death occurs in this state or whi shall be found dead therein shall not be
interred, deposited in a vault or tomb, cre nated or otherwise disposed of or removed
from or into any registration district, or e 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 i which the death occurred or the body was
found. No such burial or removal pert it shall be issued by any registrar until,
wherever practicable, a complete and sat sfactory certificate of death has been filed
with him as heretofore provided; provide 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. (A 1-95Zich. 267.)
* See section 390.
§ 379. Duties of undertaker. In e h case the undertaker, or person having
charge of the corpse,shall file the certifica e of death with the registrar of the district
in which the death occurred and obtain a urial or removal permit prior to any dispo-
sition of the body. * * * The undertaer 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; paid permit to accompany the corpse to its
destination, where if within the state of Now York,it shall be delivered to the person
in charge of the place of burial.
§ 380. Duties of undertakers; inter nt within the state. If the interment, or
other disposition of the body is to be mad 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 t inter, remove or dispose otherwise of the
body, stating the name, age, sex,cause of eath, and other necessary details upon the
form prescribed by the commissioner of h alth.
§ 381. Interments. No person in ch rge of any premises on which interments
or cremations are made shall inter or pe mit the interment or other disposition of
any body unless it is accompanied by burial, cremation or transit permit, as
herein provided. Such person shall endo se upon the permit, the date of interment,
or cremation over his signature, and s 11 return all permits so endorsed to the
registrar of his district within seven day, from the date of interment or cremation.
He shall keep a record of all bodies interr d or otherwise disposed of on the premises
under his charge, in each case stating t e name of each deceased person, place of
death, date of burial or disposal, and n e 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, 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 writc 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.
rer SEXTONS and UNDERTAKERS violating the law relative to the re-
turn 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 viola-
tinne therenf_