Mead, Polly Ann Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
irir'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..__.5 0 / Register N
County G2.1L2�.tn_,__ Date of Death 3-_--iq ,��
To, , .il- _� 37G� Sex _ Age li rs. Color Lvi�t _._
lager-or-City
(Or 1GIos.)
(Cross out names not applicable)
Cause of Deat _
'lase of-Du ' me_
(or Removal)' tery �''C&d:ea
Burial--_ - �1~I
A CER ICATE OF DEATH of
( ve fulse )
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 abc Re ¢ dN�Q,V.r,and on the bas. t reef I ' BY G;; APE MIT
to �/C�_
(Name of Undertaker) (Ad ess)
/the to___ _ ___ ____ ' th- body.
(Und or on ha ng c ar a of corpse ___(Inter,r *=� spore of[stat 7 ow))
Dated Igiij_ (Signed)- ,.- ,. our ' 0 -it/ i_ , ___
° Local Registrar
Permit is sufficient or the Removal (and Interment or Cremation)of a body to any part of the
State (su ject 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).
12.17-14-25.000(21-2566)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of
(Interment or cremation) r`
(Signed) ,.l{._ / U*"�`" /L✓
(Person t/ �^
in charge) 0
(Name of Cemetery,Crematorium,etc
Person in charge must return this Permit to Registrar o his District 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'xgz3, CHAPTER 61g,ARTICLE so.
§ 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 person in charge of the place of burial, before
interring or otherwise disposing of the body; or shall attach the removal
rmit to the box containing the corpse,when shipped by any transportation
V'repaiei permit to accompotty the corpse to its destination, where,if
within the state of New York, it he 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 bdy 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 satisfactory certificate of death,having
been Sled with him,as required by Myr,permission is granted to inter,remove
or dispose otherwise of the body,Ming the name, age, sex,cause of death,
and other necessary details upon a form prescribed by the commissioner
Df health. .
38I;*-^Interntents. No " in charge of any premises on which
,m p gave: all inter or permit the interment or other
x o littlest it accompanied by a burial, cremation or
f
t ,ch person shall endorse apon the permit,
e of inte'rntent,or&mati+' over his signature, and shall return all
perrhits so endorsed to the registra .lf his district within seven days from the
date of interment or cremation. II shall keep a record of all bodies interred
or otherwise disposed of on the pr g.-s under his charge,in each case stating
the name of each deceased person, 1 ace of death, date of burial or disposal,
and name and address of the and ,.r.et; which record shall at all times be
open to ofhtiial inspection, provid` that the undertaker or person having
charge of the corpse, when,bury' •-'a body in a cemetery or burial ground
having no person in charge, shall".t ci the burial or removal permit, giving
the date of burial,and shall write ac 4'ss the face of the permit the words,"No
person in charge," and Ele the b =`I or removal permit within three days
with the registrar of the district in ' ich the cemetery is located.
Qom'"SEXTON&f and UIWERT' ERS violating the law relative to the re-
torn of permits are liable'to a penalty•'VOT LESS THAN FIVE DOLLARS NOR
MORE THAN FIFTY DOLLARS,,,§'fR THE FIRST OFFENSE. The law
Will be'enforced. Local Regis tare required, under penalty,to report
k violations thereat. o