Acorne, Nettie Form ye.11. NEW YORK STATE DEPARTMENT OF HEALTH
ar OFFICIAL BURIAL (OR REMOVAL) PERMIT
Village, orThis Permit � be signed only by the Local Re
City) in which the death occurred after the FILING andpac epta or ance off a CORREthe CT AND COMPLETE CERTIF District A(E�OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. }} jj
yTown Registered No._..!.. ..b......
Dist. No,5t8d/ Village g'
County ,, or City
¢� V2tZt4 re )..
Name of deceased... t��' e (If Vet•. an street address)
���
ØColor
Sinle, married, widowed, VeteranSe1C 1 (If veteran, ive n e of War)
7or divorced (write the word) p Date of Death .�3 3 �' 19
Age �.3 Ye s ,S'- tils... !�Cause of Death......�� ..1 •-..Da s Birthplace /
Certificate was signed
by..-'1,�..�..- . .. ...... ....
ea L
Address77 /<, D
Place of Burial (or Removal) M. .
(If body is to be temporarily hel I•in epee ater)� "' ' ^
Cemetery
(If body ie to be temporarily be d,dl�pace later)
• Date of Burial........... . lr�,�...t 19
Then 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 accepted the same for registration, have recorded it in my Local Recor with the above stated Registered
Numr.,-and on ille b is the f I HEREBY GRANT A PERMITto 1.4414(cl .r `
the r---96,„ (-44
cfitni erne) +J
(eaa
(Undertaker r n to hold tell' or and L�� _ the body.
�`, charge of corpse)
Dated ✓. .3„ 19 \ (Inter,r �'Qv oth`wi dispose of(state howl)
• ' (Signed)If\.< l�•,.... ..
This Permit is sufficient for the Removalment ` F•�' a "� '
cemetery or other regulations), unless remorxjliabycommon o matiLn) of 31 body to I.
P ,.. .•¢ $ba �,,, �• ,d -.� ,
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR
ACRE ATIONS ARE M DE
D —_ /, -----19
(Interment n ' J
144/4
(Name of Cemeter , rematorium, etc.
Section Lo No. __ Grave No.7
(Signed)__fri7
e
( erson in c3argc)
Person in charge must return this Permit to Registrar of his District within
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
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 for burial or removal of dead bodies. The body cf 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 provided; * * *. When a dead body
is transported from outside of the state into a registration district in this state foi
burial, the transit or removal permit issued in accordance with the law and healti
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 statistic:
shall receive any fee for the issuance of burial or removal permits under this ac
other than the compensation provided in this article. Provided, however, that th,
state 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 othe
carriers engaged in the transportation of persons within this state.
§ 379. Duties of undertaker. In each case the undertaker, or person havin;
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 t
any disposition of th( body. * * * The undertaker shall deliver the burial permi
to the person in charge of the place of burial, before interring or otherwise dispos
ing of the body; or .,.hall attach the removal permit to the boy: cor.:aia ng tk
corpse, when shipped by any transportation company; said permit to accompan
the corpse to its destination, where if within the state of New York, it shall b
delivered to the person in charge of the place of burial.
§ 381. Interments. No person in charge of any premises on which into
ments or cremations are made shall inter or permit the interment or other dispt
sition of any body unless it is accompanied by a burial, cremation or transit permi
as herein provided. Such person shall endorse upon the permit, the date of inte
ment, or cremation over his signature, and shall return all permits so endorsed
the registrar of his district within seven days from the date of interment or cr
. mation. He shall keep a record of all bodies interred or otherwise disposed of c
the premises under his charge, in each case stating the name of each decease
person, place of death, date of burial or disposal, and name and address of tl
undertaker; which record shall at all times be open to official inspection; provide
that the t leltrtaker or person having charge of the corpse, when burying a bot
in a cemet'v or burial ground having no person in charge, shall sign the burl
or removal permit, giving the date of burial, and shall write across the face of tl
permit the words "No person in charge," and file the burial or removal pern
within three days with the registrar of the district in which the cemetery is locate
SEXTOS and UNDERTAKERS violating the law relative to the return of pi
mits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MOF
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforce