Potter, Frank Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ire'"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._-tF_ I Registe No. d
County Date of Death 91_
Town,Vil-
lage, or City .aikz._ Sex'Lti4 Age IColor---.� P �
(Cross out names not applicable) - (Or Mos.)
Cause of Death. A g-. t
aQ
Place of Buria
l . Ceme-
• --
serremoval} -��---..._,.... _ —tery - — ----- ° •r 9
A CERTIFICATE OF DEATH of
(Give full name f 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 ve sta ed Register Number,and on the basis a of I HER7/YaGZ A PERMIT
(Name of Undert er) (A _ess)
+..E -�''t
the th body.
( to
Undertak erson havi a of corpse)
se) (Inter,remov o wi spore of[st how])
Dated 191_.( l (Signed) F t•
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crem ion)of a body to any part of the
State (subject to local cemetery or other regulations), provided, that whet removal is by common carrier,
the above Permit must be included in the Transit Permit.
2_M_16 OK Me I11_60621
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of AA-- 7 191.6...
a(Interrn o crem_iration)
(Signed) 1 r
(Person
in charge)._.._ (
(Name'of Cemetery.Crematorium,etc.);
Person in charge must return**Permit to Registrar of his District within
SEVEN (7) DAYS from above date,; Ipso person is in charge, the UNDER-
TAKER MUST SIGN ABOVE STAT3 MENT,write across the face of the Permit
the words No person in charge,'"and'FILE PERMIT WITHIN THREE (3)
DAYS with Registrar of:District is which cemetery is located.
y
EXTRACTS FROM LAWS OF's1913, CHAPTER 6rg, ARTICLE zo.
§ 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 burial permit to the perso i charge of the place of burial, before
in rring or otherwise dis ing of:t holly; or shall attach the removal
i ittQ,tI disposing
w u �,a transportation _ ..
company; sal pe o e corpse o s""des motion, where,if
within the state of New York, it all 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 stement by the
registrar,and over his signature,that a satisfactory certificate f th,having
been filed with him,as required by Mw, fission is granted o in er,remove
or dispose otherwise of the body,static the name, ages sex,cau of death,
and other necessary details upon the preecribed`by the commissioner
of health.
§ 381. Interments. No person i ,charge o'l an` premises on which
interments or cremations are made al nter orpetitfit a interment or other
disposition of any body unless it is a ompanied by a burial, cremation or
transit permit,as herein provided. Sue person Shall endorse upon the permit.
the date of interment, or crenuition,o r his sit tore. and shalt return all
permits so endorsed to the registrar f s district within seven days from the
date of interrom t or cretaation. He sh l keep a recOt'd of all bodies interred
or otherwise disposed of on the prep ise der his chSsge,in each case stating
the name of each deceased person,pla of death,date 9f burial or disposal,
and name and'address of the underta ; Which re i hall`at all times be
open to official inspection, provi at the and I r or person having
charge of the corpse. when imiryi ,. a dy'in a etery or burial ground
having no person in:charge ,Cball gm he burial re iova1 Permit, giving
the date of burial,and shall to ss"he face of the permit-the words,`No
person in charge," and tte , " b al r removal permit within three days
with the registrar of the dh �ct tea', hi the cemetery is located,
riir SEXTONS and UNRERTh E S viola the law relative to the re-
turn of permits are liable tp a qf T LESSiQ OLLARS NOR
MORE THAN FIFTY DO F THE OFFENSE. The lato
will be enforced. Local Registrars are required, under penalty, to report
violations thereof.