Brower, Thomas Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
-This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registre-
Lion District (Town,Village,��or City) in which the death occurred after the FILING and acceptance of aCOR-
R1 CT.AND - �y 'CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Q ,:
-Dist: Rio.... C - Registered No.
County Date of Death ,� `3—j�1,9r
1 ;PT' � ..
Cit - ..Q��'.�� --�---........ Sex.. Age__a1',Z Yrs. Dior- --- •--.
= ra r Mos.)
,.:{ �3ttt names no phcabl)
`Cause of Deat
Place of Burial Cei'
" ate of Burial
(or Removal) t .
• A CERTIFICATE OF DEATH of
(Give full 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 has' thereof I HER
;�n�Y/�GRANT A PERMIT
(Na of U er) ( s
the_ _ to the .
(Und; ak, or person having charge of corpse) (Inter, ove o erwi s state WI)
Dated__' _ lJ f 191.1Q (Signed)
Local Registrar
1,lis P-�'t is sufficient for the Removal (and Interment or atio of a body to any part of the
State (subject to local cemetery or other regulations), provided,tha here moral is by common carrier,
the above Permit must be included in the Transit Permit.
12.60-16r41i_lIM magnet
ENDORSEMENT or SEXTON OR PERSON IN
CHARGE OF PRE ISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of r9r 6
teaspent or es)
{Signed).__.--•.- -. ,
(Person
in charge) '''"''4,
(Name of tuetery, ,)
Person in charge must return, 's Permit to Registrar of his District within
SEVEN (7) DAYS Ir om above deft. If no person is in charge, the UNDER-
TAKER MUST SION ABOVE STA MENT,write across the face of the Permit
the words "No person in charg 1 and FILE PERMIT WITHIN THREE (3)
DAYS with Registrar of Distric i which cemetery is located.
EXTRACTS FROM LAWS 0 1913, CHAPTER 619, ARTICLE 20.
§ 379. Duties' of undertaker. In each case the undertaker, or person
having charge of the corpse,shall e 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 e body. * * * The undertaker shall
deliver the burial permit to the pe on in charge of the place of burial, before
interring or otherwise disposing o`:the body; or shall attach the removal
permit to the box containing the eG ae,when shipped by any transportation
company; said permit to accomp:',y the corpse to its destination, where,if
within the state of New York, it all be delivered to the person in charge
of the place of b 'al.
§ 380. Duti of undertakers; interment within the state. If the inter-
ment,or other dis osition of the bo is to be made within the state,the word-
ing of the burial r removal perm t may be limited to a statement by the
registrar,and over his signature,thst a satisfactory certificate of death,having
been filed with him,as required bylaw,permission is granted to inter,remove
or dispose otherwise of the body, ating the name, age,sex,cause of death,
and other necessary details upon a form prescribed by the commissioner
of health.
§ 381. Interments. No perso in charge of any premises on which
interments or cremations are made s all inter or permit the interment or other
disposition of any body unless it i accompanied by a burial, cremation or
transit permit,as]herein provided. uch person shall endorse upon the permit,
the date of interment, or crematio over his signature, and shall return all
permits so endorsed to the registrar f his district within seven days from the
date of interment or cremation, H shall keep a record of all bodies interred
or otherwise dispo d of on the pr es under his charge,in each case stating
the name of each leceased person, ce of death,date of burial or disposal,
and name and address of the nude aker;'which record shall at all times be
open to official inspection, provi that the undertaker or person having
charge of the corpse, when buryi to body in a cemetery or burial ground
having no person in charge, shall s n the burial or removal permit, giving
the date of burial,'And shall Write ac ss the face of the permit the words,"No
person in charge," and Ele-the hu or removal permit,within three days
with the registrar of the district in ich the cemetery is located.
SEXTO�a�1S and UNDERT ES violating the law rotative to the re-
turn of permits area iable to a penalty LESS THAN FIVE DOLLARS NOR
MORE THAN F Y DOLLARS THE FIRST OFFENSE. The law
will be enforce Local Regis required, under penalty, to report
violations thereof., ,.,