Donner, Winona VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
Na/ me: First�j' le t Sex
Date of Dea fr.pil Age If teran of U.S.Armed r arVs
PI. :/seatO ,Tow or Village H pital, Institution or Street Address
,�,.- - of De
W
A Me I rtifier: ee e d s
Deat fi to Filed: ' n or Vil Dis nct o. egister No.
' � Date
ial: /f. ete or Cr'efnatory ddre
1
❑ Cremation: -emu�i.C�.t!/�' ^ r'
. 7
Removal Date Place Removed and/or Held dress
C ❑ and/or Hold:
I-4
rn Date Point of Shipment Destination
Transportation by
13.1 ❑ Common Carrier:
ADate Cemetery Address
Disinterment:
0
•interment: im
Per ,f I sued :N m- of F. eral Firm Add Registrationo.
f krt� ` - �� 0 9.
me o un' eral Firm Ma g isposition or horn Remains artrShipped,Tf'ptker;i ove:
(~ Address:
aPermission is her ranted toted pose of the dead human remains described abov 'ndi .
W Date Issued �d"��f
p Regis rar of Vital Statis ics nature)
District No. ..�! . I
Place //
his permit must be completed on back by the person in charge at the place of disp with 1 egistr r o v�tais�::f the city,tovlage
where disposition took place.
PUBLIC HEALTH LAW
§4145. Deaths; burial and removal permits; disposition of remains.
1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompanied py a burial,cremation or transit permit,as provided
in this article.
2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before
interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any
transportation company,which permit shall accompany the remains to its destination,where if within this state, it shall be delivered to the
person in charge of the place of burial or other disposition.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of
interment, cremation or other disposition.
4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the
funeral director or undertaker shall(a)sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the
words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is
located.
5.The person in charge of the place of burial,cremation,or other disposition 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 funeral director or undertaker, which record shall at all times be open to official inspection.
ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES. c�
I certify that the remains were disposed of in accordance with the permit on the reverse side on 41 C / cV y
/ (Dater
at �V e �f e C et C ,-- N.0.) 4
(Place of disposttion and ad res
Section 7-GL 4 Z_4. Lot No. r Grave No. 3
SignatureetC12441 fri/Z,CPQ_ Title