St. John, Florida Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can he 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, LEGIBLY WRITTEN IN DURABLE BLACK IN1C. Town Registered No—.V/....1.......... ,
Dist. N0.4.-.‘a./..County...-.:74—a-22-te.tt. Vill or C age .....„e:444, ...47,..,. ,
ity
..(4
(If city, give street address)
Name of deceased. r-79-101-7244 Si. StAdr-411 Veteran
Single, married, widowed,
Sex-4744/1.0kolor..,,,T4.44r:or divorced (wnte the word).gi...iner," (If veteran. give name of War)
Date of,Death ./.4/7 .., ...„19..4.7.3
Age 4,7 Yea 7 Months.... .,..‘.....-...Days Birthplace.....):27..a.eveze..4.424.fen-..,...Q.4....s
Cause of DIreath
Certificate was signed by 30. ge#4,:!.. M.D.
Address. ../P.4tva .,. )74Le7
Place of Burial ,or Removal) -.7 1 '
.
s
(If body i.I I to be te a k space lat
Cemetery ,. .C.t.ra,.., Date of Burial 1/7/ 0 19..47,3
(If body is to be temporarily old,fill in space later)
Thu 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 have acce•ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, asist11, f I IIEREpY GRANT A PERMIT /n, /
lih "------„: (Address)
/.S%.94,,e..'711reLrf,1,,..-
the to hold tcmpo 'ly and \•., -r12:ff , the body.
‘, (UndErtaker or pa a having charge of corpse) ' (Inter, lit ore, .r . ad i- ; ricell:tga bowl)
Dated ././ / 0 19.473 (Signed '
This Permit is sufficient for the Removal (and Interment entation) o body to ny part •f the State (subject to local
cemetery or,other regulations),unless removal is by common ea , in which ca a Transit Permit (VS No. 62) is required.
PREMISES ON WHICH INTERMENTS OR ay v+
CREMATIONS ARE MADE
Date of_.. was--/ j r 0 19_"' 3
vtqrmen o?,-ir a thin,
aste ( ame of Cemetery,Crematorium,eta.)
Section Lot No Grave No
(Signed) (j._---a-( A4g ___
Person in charge)
Person in charge must r rs Permit to Registrar of his District within
SEVEN (7) DAYS from a ye date. If no person is in charge, the UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the face of the
Permit 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„ r burial or removal of ad;bociies. The body of any person
,yr $,e-4e th occurs an (his stato or wvfish.;ti 11 be ound dead therein shall not
he 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 provided; * * *. 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. Nq 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
state commissioner of health shall have power to promiulgate rules with reference
to the removal of bodies of persons whose deaths occ u!rr on trains, boats or other
carriers engaged in the transportation of persons within this state.
§ 379. Duties of undertaker. In each case the undertaker, or person having
charge of the corpse, shall file the certificate of death with the registrar of the dis-
trict in which the death occurred and obtain a burial or removal permit prior to
any disposition of the body. * * * The undertaker shall deliver the burial permit
to the person in charge of the place of burial ,j,efoe interring or otherwise.disos-
-intr"617-fife"15-6ff!!t—ef"sflall-atfacti"the ceniov permit "nrstvtl;;,bc? cc ntaming t'K'""'
corpse,when shipped by any transportation company; said permit to accompany
the corpse to its destination, where if within the state of New York, it shall he
delivered to the person in charge of the place of burial.
§ 381. Interments. No person in charge of any premises on which inter-
ments or cremations are made shall inter or permit the interment or other dispo-
sition of any body unless it is accompanied by a burial,cremation or transit permit,
as herein provided. Such person shall endorse upon the permit, the date of inter-
ment, 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 interment or cre-
mation. 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 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 write 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.
SEXTONS and UNDERTAKERS violating the law relative to the return off per-
mits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.The Yaw will be enforced.
ncal Registrars, are required, under penalty, to report violations thereof.