New Jersey Department of Health Office of Statistics and Registry P. O. Box 370 Trenton, NJ 08625-0370 QUARTERLY REPORT OF NON-EDRS BURIAL PERMITS ISSUED NOTICE TO REGISTRAR: The form is to be used when forwarding Fees for Non-EDRS Burial Permits to the New Jersey Department of Health, Office of Vital Statistics and Registry, in accordance with P.L.2007, c.98 and R.S.26:6-17. INSTRUCTIONS: 1. Fill in your 5-digit Vital Statistics code (V-code). 2. Enter the Period Ending Date. On the right side of the form, select the appropriate quarterly period to correspond to the Period Ending Date. 3. Enter the number of Non-EDRS Burial Permits issued for the quarter. 4. Multiply the number of Non-EDRS Burial Permits issued from Line 3 by the appropriate fee (currently $5.00). Enter the total amount due for the quarter. 5 Print the name of your municipality and county. 6. Sign and date the form. The reports are to be completed and submitted with your payment on a quarterly basis and must be sent within the 30-day period following the end of each quarter. If no Non-EDRS Burial Permits were issued during the quarter, indicate on Line 3 and fax the form to (609) 341-2007. “NONE” Registrar: Please complete all requested information. REG-69 MAR 18 This report identifies the number of Non-EDRS 1. Vital Statistics Code (V Code) (5 digits) Burial Permits issued for the calendar year indicated (entered into #2 on left): 2 0 / / 2. Period Ending Date October-November-December July-August-September 3. Number of Non-EDRS Burial Permits Issued April-May-June X $5.00 = January-February-March $ 4. Total Amount Due Make check for Amount Due” payable to: “Total State of New Jersey” “Treasurer, 5. Municipality/County Name: Mail to: New Jersey Department of Health Office of Vital Statistics and Registry 6. Signature/Date: Burial Permit Fees P. O. Box 370 Trenton, NJ 08625-0370
New Jersey Department of Health Office of Statistics and Registry P. O. Box 370 Trenton, NJ 08625-0370 QUARTERLY REPORT OF NON-EDRS BURIAL PERMITS ISSUED NOTICE TO REGISTRAR: The form is to be used when forwarding Fees for Non-EDRS Burial Permits to the New Jersey Department of Health, Office of Vital Statistics and Registry, in accordance with P.L.2007, c.98 and R.S.26:6-17. INSTRUCTIONS: 1. Fill in your 5-digit Vital Statistics code (V-code). 2. Enter the Period Ending Date. On the right side of the form, select the appropriate quarterly period to correspond to the Period Ending Date. 3. Enter the number of Non-EDRS Burial Permits issued for the quarter. 4. Multiply the number of Non-EDRS Burial Permits issued from Line 3 by the appropriate fee (currently $5.00). Enter the total amount due for the quarter. 5 Print the name of your municipality and county. 6. Sign and date the form. The reports are to be completed and submitted with your payment on a quarterly basis and must be sent within the 30-day period following the end of each quarter. If no Non-EDRS Burial Permits were issued during the quarter, indicate “NONE” on Line 3 and fax the form to (609) 341-2007. Registrar: Please complete all requested information. REG-69 MAR 18 1. Vital Statistics Code (V Code) (5 digits) This report identifies the number of Non-EDRS Burial Permits issued for the calendar year indicated (entered into #2 on left): October-November-December July-August-September April-May-June January-February-March Make check for “Total Amount Due” payable to: “Treasurer, State of New Jersey” Mail to: New Jersey Department of Health Office of Vital Statistics and Registry Burial Permit Fees P. O. Box 370 Trenton, NJ 08625-0370 2. Period Ending Date / / 2 0 3. Number of Non-EDRS Burial Permits Issued X $5.00 = 4. Total Amount Due $ 5. Municipality/County Name: 6. Signature/Date:
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