James, Virginia Form TEL al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTilgI�C°�T OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Resist No.._Z ! .
4 d` � Village
`�,Dist. No County' or City
• (If eity, give street address)
Name of deceased --)Y a''"'`'�� Veteran
Ingle, marrie doomed' (If ve . give name of War)
SColo or divorced ( the word) Date o th r ,� 193
Age Years onths... �i¢.
g ...D Birthplace� `-�
Cause of Death
Certificate was signed by / ,. „u.,., M.D.
Address ,.,. ��,,
Place of Burial ( emoval .. ... f.e..- .,,,r
(If body is to be to o ly held 1 i I ) _55
Cemetery.. .r Dat:ofBial
.1)-0. •'// 1 �./
95
(If body is to be temporarily held,fill i ace later)
Thq Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I ha a acre ted t e same f gistration, have recorded it in my ,,, ,cal • • mod with the above stated Registered
Nu on bag' ereo HEREBY GRANT A PER
to
c r
NanaeD f:A6-f
- ,,,
i (Ad
to hold mp• 'ly an. the body.
(Unde or person haying charge orpse) / (Iot ,ri.ove,or otherwi no fate how))
Dated ...AC—,.....(,- 19. . . (Si a,,.:• - X....
Log Registrar _
This Permit is sufficient for the Removal (and Interment or Cremation)(a • .. - y part of the State j to local
cemetery or other regulations),unless removal is by common carrier, in which case Transit Permit (VS No. 62) is req fired.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE M (� t
Nits of — .'V 19.5
(Interment or cremat n
;Signed) li-
(Person � p (�
n charge) ... IC1ik''''.a 1� / �"
(Name of Cemetery, Crematorium, etc.)
Person in charge must return this Permit to Registrar of his District within
iEVEN (7) DAYS from above date. If no person is in charge, the UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the face of the Permit
:he 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 disposition
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 pro-
vided; * * 1 *.When a dead body is transported from outside of the state into a
registration district in this state for burial, the transit or retnoval 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 transportation of persons within this state.
.See section 390.
§ 379. Duties of undertaker. In each case the undertaker, or person having
cha.ge 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 disposition
of the body. • t • 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 trans-
portation 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.
§ 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
unless it is accompanied by a burial, cremation or transit permit, as herein provided.
Such person shall endorse upon thi 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 interthent or cremation. He shall keep a rtcord•of all bodies
interred or otherwise disposed of on the premises under his charge, in each cas*stating
the name of each deceased person, place of death,date of burial or dtspoiaal,aril..name
and address of the undertaker; which record shall at all times be oppto Mficial inspec-
tion; provided that the undertaker or person!caving charge of the corpg,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, aride4 shall write acro thace of the
permit the words "No person in charge," and file rial or rem perms within
three days with the registrar of the district in whi " ` e cemetery is 1 aced.
SEXTONS and UND AKERS violati .c law relative to the return of
permits are liable to a penalty NOT LESS TH FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS„FOR THE FIRST OFFE SE. The law will be enforced.