King Jr, John Form Fa,IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can In 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 CERTIFICAT&OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No Cs,
Village -
---
or City e2 5 731-0-11.--.Q. , •, , pj?tfece,,,,„
(If city,give street address)
•
qame of deceased. " 4-4--" C-4-44 Veteran *)"2-.17 ``.'
e.
;> ... Color Single, married, widowed, \,.,_ ....,. (If veteran. give flames2 of War)
or divorced (write the word).C,T Date of .V.I'eatIr/roar-4 .01.191-5-i
kge c 5V Years ".. Months............/.......Day Birthplace tr ar3"''-' -'4C 4. --2"417.•
2ause of Death
:ertificate was signed by • 7.,..- - „..7P... ......4el 04-r-4,„.." M.D.
Address... . -71.-.,,e_Air -2't-i
'lace of Buzisnoval) 7.:17-1.1.4
):
me -...1„,ig,c2-4-11
If body la t be llempor ly held,Ill inpmfabr)
:eetry... ..L1-...*:1,6.4- Date of.Burial 0 iekv-.4--are. ..eRet.3....19,)71.
If body is to be temporarily held,fill in space later) -
rhe 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,
have accepted the same for re "stration, have r .rded it in my Lo cor wi the above stated Registered
in , and on the a • HEREBY '4 NT A PERMI
v eg2. eer 1
)
• Ile s) 'i ?..441.. •-•
it .... -.' old tempor and the body.
( er or pa...totrigg etkarge gLoorpae) (Inter re e,or otlr, n of[state bow])
)ated'.. (Sign .c
Loc Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y y pert of the (subject to local
ornotiare nr'eattuar rdsenilmtmnal unl..............1 I. 1......................f.., :- ---LI-L ---- - •r----t. 0---.1. /VC xt- an• .:- -----:.--.1
ENDORSEMENT OF SEXTON OR PERSON INCHARGE OF
PREMISES ON WHICH INTERMENTS OR
CREMATI AR _- E�j
Date of .G',22s t.... . ... ,........ . S.. 's' 111.5 I
(In cane ice)
(Signed) .. .._
(Person - - -
in charge) .. .;,,y/ y1,.l.:dr. 44}". 22 .,,,,r�r 1 1� !.
(Name of Cemetery, Cremator um, etc.)
Person in charge must return 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 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 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 remove,
from or into any registration district,or be temporarily held pending further dispositio:
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 occurrei
shall be given the same force and effect as the burial permit herein provided for. NI
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 wit]
reference to the removal of bodies of persons whose deaths occur on trains, boats o
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 ii
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 charg,
of the place of burial, before interring or otherwise disposing of the body; or shal
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 i
within the state of New York, it shall be delivered to the person in charge of the plac
of burial.
§381. Interments. No person in charge of any premises on which interments o
cremations are made shall inter or permit the interment or other disposition of any bod;
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 oyei hi.
signature,and shall return all permits so endorsed to the registrar of his district withii
seven days from the date of interment or 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 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 thi
permit the words "No person in charge," and file the burial or removal permit withii
three days with the registrar of the district in which the cemetery is located.
SEXTONS and UNDERTAKERS violating the law relative to the return o
permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORI
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced
Local Registrars, ere required, under penalty, to report violations thereof.