Lee, Margaret Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
VT"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. 0-6,,a, Registered No.
County Xt=L L. ate of Death /
_ I I.�
Towu,Vil- /
X7.if. -l/,G____�,'?),` Sex_.___L_. Age_rfaf / rs. Color__ _
lager or City o
(Cross out names not ap able)
Cause of Death-- !- - ._ ---- �n- -__
Place of Burial /�y -� Ceme- Date of Bun ` (• / 91--
(or Removal) ery
A CERTIFICATE OF DEATH of-_^_
(Give full name of deceased) -
having been presented to me containing the abo stated particulars,and,after careful examination,
the same appearing to be COMPLETE, CORRE , AND SATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Record with
the a ove ated Registered N tuber,and on the basis h eof I HERE GRANT A PERMIT
to ?/� ,
r� roc -'�-�-
(Name Unde ( )
the-_-_ _ _ to the body.
(U�y�rtale or pg having charge of corpse (Inte r ovwr of se dispo of[state how])
Dated___ 'k/''//,��__ //]]CC f/ 191_6 (,Signed)____ _ - !/0-
Local Registrar
This Permit is sufficient for the Removal (and Interment or r a io f a body to any part of the.
State (subject to local cemetery or other regulations), provided, that here re oval is by common ca - ,
the above Permit must be included in the Transit Permit.
5.27-15-25,000(21-68931
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
M T •R CREMATIONS ARE MADE
' ...
Date of ft-E.a.N #' tor..
• nterment or c}mation)
(Signed) .. =. - : ”are:e.Wv
(Person /.'2 f f,
in charge),.,.1.:...,.-""r`r!s.�+ �„' �.![.��Sb..
(Name of Cemetery.Crematorium,etc.)
Person in charge must return this Permit to Registrar of his Distrit 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 FROM LAWS OF rem, CHAPTER big, ARTICLE 20.
§ 379. Duties of undertaker. In each case the undertaker, or person
having charge of the corpse,shall file the certificate of death with the registrar
of the district in which the death occurred and obtain a burial or removal
permit prior to any disposition of the body. * * * The undertaker shall
deliver the bifrial permit to the person in charge of the place of burial, before
interring or otherwise disposing of the body; or shall attach the removal
permit to the boa containing the corpse,when shipped by any transportation
cotapatiy; said permit to accomtiany the corpse"to Its destination, where,if
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,end over his signature,that a satisfactory certificate of death,having
been fi1Qd 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 cremations are made shall inter or permit the interment or other
disposition of any body unless it is accompanied by a burial, cremation or
transit permit,as herein provided. Such person shall endorse upon the permit,
the date of interment, or cremation,over his signature, and shall return all
permits so endorsed to the registrar of his district within seven days from the
. date of interment or cremation, He 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 undertaker; which record shall at all times be
open to official inspection, provided that the undertaker or person having
charge of the corpse, when burying a body in a cemetery or burial ground
having no person in charge,*hall sign the burial or removal permit, giving
the date of burial,and shall write across the face of the permit the words,"No
person in charge," and Fie the burial or removal pern;it within three days
with the registrar of the district in which the cemetery is located.
Or SEXTONS And'UNDERTAKERS viola' the law relativeto the re-
turn of permits are liable t0 penalty of NOT LESN FIVE DOLI,wRS NOR
MORE THAN FIFTY DOLLARSOR THEIS OFFENSE. The law
will be snforeed. Local Registrars are required, under penalty, to report
violations thereof.