Haviland, George E Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
tt
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(W'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District (Town,Village, or City) in which the death occurred after the FILING and acceptance of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No._�,d 61'a Registered No. 2 s
County YJ Gl''► ri4 Date of Dea `!,.
Town
Vil-
Iage, or City Sex7,4-4_ Age q C Yrs. Color 01'4.'
(Cross out names not applicable) (Ur Mos.)
Cause of Death___J4.-�-� _-_ _
Place of Buria Ceme- Date of Burial_ -_ __1g1,�^
(o7 Removal) ter `�
A CERTIFICATE OF DE H of
-sit
' (Giv�II name of deceased)
having been presented to me containing the above stated particulars,and,after careful examination,
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 Record with
the above stated Registered Number,and on the basis thereof I
HEREBY GRANT A PERMIT
to
(Name oFUndertak r) ( dress) ,
the-__L.L C., .- to e1. the body.
(U rtaker or person having charge of cor se) (Inter,r e�9r oth s se,of jstate how])
Dated-__-.____ 7 I9I- ^ (Signed) �'�G�/ is'
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the
State (subject to local cemetery or other regulations), provided, that where removal is by common carrier,
the above Permit must be included in the official Transit Permit(Form VS No.62).
12-17-11-2b,000'(21-2586>
ENDORSEMETT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTp 1.M. CREMATIONS ARE MADE
Date of 194-
,„ te e t or 'natio
(Signed), '
(Person
in charge) -J`C't-gfeV
fYLT 4.*04,1
,< ante of e y, ensatorium, Tr
• Person in charge ,•ust return this Permit to Registrar' f his District within
SEVEN (7) DAYS fr.', above date. If no person is in:harge. the UNDER-
TAXER MUST SIGN :OVE STATEMENT,write across'••4 face of the Permit
the words "No perso in charge," and FILE PERMIT, ITHIN THREE (3)
DAYS with Registrar of District in which cemetery is,ocated.
EXTRACTS FR s•• LAWS OF ro13, CHAPTER 6• ARTICLE so.
§ 379, Duties o;undertaker. In each case the 'dertaker, or person
having charge of the c rpse,shall file the certificate of d ;th with the registrar
of the district in whi h the death occurred and obtai.-a burial or removal
permit prior to any .sposition of the body. * * he undertaker shall
deliver the burial pe it to the person in charge of the ace of burial, before
interring or otberwi disposing of the body; or sh.. 1 attach the removal
Permit to the box co. aining the corpse,when shipped ant7 transportation
..-....ewato..--seel-iperietiteat-e-eteeennymety.eke- .
within the state of New York, it shall be delivered to the person in charge
of the place of burial.
§ 380, Duties of undertakers; interment within the state. If the inter-
ment,or other disposition of the body is to be made within the state,the word.
ing of the burial or removal permit may be limited to a statement by the
registrar,and over his signature,that a satisfactory certificate of death,having
been filed with him,as required by law,permission is granted to inter,remove
or dispose otherwise of the body,stating the name, age,sex, cause of death,
and other necessary details upon the form prescribed by the commissioner
of health.
§ 381, Interments. No person in charge of any premises on which
interments or cremati..s are made shall inter or permit the interment or other
disposition of any bt:oy unless it is accompanied by a burial, cremation or
transit permit,as here provided. Such person shall endorse upon the permit,
the date of intermen. or cremation,over his signature, and shall return all
Permits so endorsed t.the registrar of his district within seven days from the
date of interment or•• ation. He shall keep a record of all bodies interred
or otherwise disposed ' on the premises under his charge,in each case stating
the name of each dee,' person, place of death,date of burial or disposal,
and name and addres of th.:. undertaker; which record shall at all times be
open to official instle. 'on, provided that the undertaker or person having
charge of the corpse, 'hen burying a body in a cemetery or burial ground
having no person in .arge, shall sign the burial or removal permit, giving
the date of burial,an. -hall write across the face of the permit the words,"No
person in charge," a. Eta the burial or removal permit within three days
with the registrar of • - district in which the cemetery is!jocated.
M—SEXTONS •• d UNDERTAKERS violating the law relative to the re-
turn of permits are liab to a penalty of NOT LESS THANsFrilk DOLLARS NOR
MORE THAN FIFT DOLLARS FOR THE FIRST OFFENSE. The law
will be enforced. •cal Registrars are required, under penalty, to report
violations thereof.