Potter, Charles Form v&FL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
d' 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 CERTI If.T OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town �j �rRe "sttte�red No.Y.._.!o ..-11--_.....__
.ft
O Q Village / ^. ....5 ' ��+ '�.e." a."-e..
Dist. No,y G � couatyV" or lag
(If city, give street address)
game of deceased Veteran 2"2"6
Single, married, widowed �j� ' _- . (If veteran give I e of War)
Se J -Col or divorced (wnte ord)C(/'«a`'' Date QfAleath. ' "Z 719`� /
kge G 7 Years .� Month . . r`-- Birth ./� "L(- .�g Day aye `7
ause of Death--
.
Zertificate was signed by e M.D.
Address..... . ....... ,�,,,i ....Zit,. ... �• •r
Place of Burial (or Removal) .p' -
;I!body Is t be zip rarilp d,fi ace later
Cemetery. .. .. ..N. ,� ^-�+ Date of Burial... 3 ' 19
If body is to be temporarily held,fill in space later)
Me Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
lation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
f have a pted the same for registration, have recorded it in my Lo 1 Record with the above stated Registered
he
Vu ern don the as' treofH BY GRANT A PERMI .
f
o. N me)� Address) :e5
he.... to hold t -a y and the body.
al er or rson hiving ebarrggu�.p�fr corpse) ante re .v ,or oth-rwi f s/ state bow])
dated' VS c) 19 .e.. (Si
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mate feet to local
*meters or other regulations).unless removal is by enmmnn.r,r►ier_ in ...tii..h ..... . T.....:. a.....i. (VS N.. a91 :. ......:....a
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
CR ATIONS ARE MADE
}c3)
Date of _ _._............ .. 19
(Interment or cremation)
(Signed) , . t ••C C C ,y�
(Person /��Z '"t' // in
in charge) �-
f' 6N�ery, •C're at�'riuta,ete.�
Person tit' ust turn this Permit to Registrar of his District withii
SEVEN (7) DAYS from above date. If no person is in charge, the UNDER
TAKER MUST SIGN ABOVE STATEMENT, write across the face of the Perini
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 perso:
whose death occurs in this state or which shall be found dead therein shall not b
interred, deposited in a vault or tomb, cremated or otherwise disposed of or removes
from or into any registration district,or be temporarily held pending further dispositioi
more than seventy-two hours after death unless a permit for burial, removal, or othe
disposition thereof shall have been properly issued by the registrar of vital statistics o
the registration district in which the death occurred or the body was found. No sucl
burial or removal permit shall be issued by any registrar until, wherever practicable,
complete and satisfactory certificate of death has been filed with him as heretofore pro
vided; * * * *.When a dead body is•transported from outside of the state into
registration district in this state for burial, the transit or removal permit issued it
accordance with the law and heath regulations of the place where the death occurre(
shall be given the same force and effect as the burial permit herein provided for. N(
registrar of vital statistics shall receive any fee for the issuance of burial .;r remova
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 witl
reference to the removal of bodies of persons whose deaths occur on trains, boats oi
other carriers engaged in the transportation of persons within this state.
'See section 390.
§ 379. Duties of undertaker. In each case the undertaker, or person havini
cha,ge of the corpse,shall file the certificate of death with the registrar of the district it
which the death occurred and obtain a burial or removal permit prior to any dispositioi
of the body. ***The undertaker shall deliver the burial permit to the.person in chargi
of the place of burial, before interring or otherwise disposing of the body; or shad'
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
within the state of New York, it shall be delivered to the person in charge of the placi
of burial.
§ 381. Interments. No person in charge of any premises on which interments oi
cremations are made shall inter or permit the interment or other disposition of any bod3
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 ores hit
signature,and shall return all permits so endorsed to the registrar of his district withit
seven days from the date of interment of 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 official 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 buria
or removal permit, giving the date of burial, and shall write across the face of th(
permit the words "No person in charge," and file the burial or removal permit withir
three days with the registrar of the district in which the cemetery is located.
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.