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Wagner, Edmound Form VS.a. NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT tr This Perndt 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�c OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._.,r.00. ___ Dist. No,.dll./...Coun Village ty., ta". ~f?:!"" or City -- ', - (If city,give street address) game of deceased.. ....e rG7 ,a1ts Veteran --14.0 Single, married, wido� (If veteran, give name of Wu) Sex Color... or divorced (write the word)..a Date of Death.. 777 . i 19 kge..h1`.s":._, Y rs 4. Months...., .. r�.iff ..,Days Birthplace... i fr 'guar of Beath. .�� ... ,,7. .. ... ... y Certificate was sign l ;! / M.D. Address............ !T .. ,, ...�a ?lace of 1Bui4al (or Removal)....r tair>+-./.. ..444.fra-pegt.elfuvr If body is t; be tenornarily held,fill in space later) Cemetery.••.. .ere f- +Y Date of Burial - /...br 19„>"'1. If body is to be temporarily held,fill in apace later) Phe Certificate of Death containing the above stated particulars, having been presented to me, after careful exami- iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, have accepted the same for registration, have recorded it in my Local Record with the above stated Registered dumber, the bat thereof I HEREBY GRANT A PERMIT / , he.... (U e w•N`s (Address) to hold tempora and //////jjjjjj������ the body. estates or n haying charge of corpse) (Inter re • , r otherwl ais tate how]) )ated:. ,. C,.J..l 19.. ./.. (Signe ll...a...... Registrar This Permit is sufficient for the Removal (and Interment or Cremation) o a y to any pant of the State ( ject to local emeter7 or other regulations).unless removal is by common corder_ in rrlac6 pa an a Tranai! P.,.,rn! (VS N. R21 is tinviand_ ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR `-CREMATIONS A E MADE Date �.!:*-4147.i!1.. Al 11 19 (Int nt n) " , (Signed) (Person. , r ... in charge -� � ,[�r..:: .:2 .4d/!. „ (Name of Cemetery, Crematorium, te.) ,;i) f.. Person in charge must return this Permit to Re strar of his Distrietfiii 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 Permi 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 persoi 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 an) 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 health regulations of the place where the death occurret shall be given the same force and effect as the burial permit herein provided for. lit registrar of vital statistics shall receive any fee for the issuance of burial or 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 a 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 it which the death occurred and obtain a burial or removal permit prior to any dicpositioi of the body. * s*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 shay, 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 plan of burial. §381. Interments. No person in charge of any premises on which interments a 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 oyes hi: signature,and shall return all permits so endorsed to the registrar of his district withit seven days from the date of interment pr cremation. He shall keep a record of all bodie, 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 namt 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 thi 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. 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.