Van Rhijn, Merriam Form 4 V.S. The Legal Fee For This Permit Is $1.00 Reg. 21 36 l
Dec. 61
STATE OF NEW JERSEY BURIAL OR REMOVAL PERMIT V N.a
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Hackensack Sept.11,,..., 19 74 ° o
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(City, borough or township and date) N v v
The Certificate of Death having been filed with me, as required by the laws of this State, permission is 4 0 0
hereby given for the removal, burial, or other final disposition of the body of .,g
Merriam G. Van RhUn 0.0.°.`
S7 F Jersey City Sept. 3 19, 74 2 v l y
age. sex who died in on
Cause of Death Carcinoima. of Uterus with itetastases v o °'v
?a°y
Proposed Place of Removal, Burial or .b'y o
other Final Disposition Say Tefilah Cam. Glens Falls, N.Y, v °
Place Location ` N
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Funeral Di�ctor ° av v
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...11 .. wdqui..2894 _ .. E 4 Y
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Hackensack,N.J. L(9 o ova H di.t4ezy..6a 4:c
(Address) (Registrar of Vital Statistics) E" >.
Penalty For Burying Without a Permit, $5 to $100 a w f,41.
STATE OF NEW JERSEY
BURIAL OR REMOVAL PERMIT
(Name of Deceased)
(Date of Burial or other Final Disposition)
(Signature of Superintendent of Cemetery or Crematorium)
This permit must be delivered to the superintendent of
the cemetery or crematorium where burial or cremation is to
take place, who should fill in the spaces above and forward
it within ten days to the registrar of the district in which
the cemetery or crematorium is located. Registrars are usually
health officers, city and borough clerks and assessors of
townships.
When burial takes places in a cemetery which has no
person in charge, the spaces above should be filled in by
the funeral director, who should write "no person in
charge" on the line for signature of superintendent of
cemetery and file the permit with the registrar of the dis-
trict in which the cemetery is located. The law requires
that this be done within ten days after burial.