Gilchrist, Frank Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District (Town Vitt; .s stdsj,,'-`I.c d:eatle.e aw ....is►.Ll. 'lL- &. of"a'8Oft
li i�i ^' PIPET ATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.. _ Registered No
County _-. Date of Death. P ' < 191
,ear-Ym
ingP,nr.City .., ..._. Sexi. Age( _ O___Yrs. Color_.
(Cross out names not applicable) _
Mos.)
Cause ofDeath �pplic_.._�- -_- -_______- ""'
Place of Burial �� � Ceme ._ D e of B ��- �:_x9xi�
Place
Removal) ' tery
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, AN)=)^,SSATIISFACTORY AS REQUIRED ]}
T
h,AAW,L have-accepted the same for registration, have recorded it in my Local Record with
the a ove stated Regi tereber,and on the basis h reof I HER B GRA A PERMIT
: Namf( (Ad )
unrA
_ .. . . to _._..._� the body.
(U ertaker or per having charge of co se) (Int o�j�or wise di oseS of[state how])
Dated fl IgLie (Signed)__ —..0_:._
Local Registrar
This Permit is sufficient for the Removal(and Intermen o on)of a body to any part of the
State (subject to local cemetery or other regulations),provided, at whe a removal is by common carrier, ,
the above Permit must be included in the Transit Permit
12.80.1b25,000(21-18047)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON W ICH INTER-
ME ITS OR CREMATIONS ARE MADE
Date of k r 11 � ?ntimet orcreLon),
* 191 ?
(Signed)
(Person
in charge)_ &7.-' '4 0.444"4,474. —
, (Name 0 Cemetery,C+ t,etc.)
Person in rge must return this Permit to Registrar of his District within
SEVEN (7) D S from above date. If no person is in charge, the UNDER-
TAKER MUST GN ABOVE STATEMENT,write across the face of the Permit
the words "N person in charge," and FILE PERMIT WITHIN THREE (3)
DAYS with Registrar of District in which cemetery is located.
EXTRACTS FROM LAWS OF r913, CHAPTER 619,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 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
Pet .it to the box containing the corpse,when shipped by any transportation
i, , • •. OW the ,q x destination, whereof
.'' :4 o Cew ork,`if fball1be c• � A'to the`person in charge
of the place •' urial. c '
f, .t ' of undertakers,, Interment ' e state. If the inter-
ment 13 f position of the body is to be in' 4 ►n the state,the word-
,, i b or removal permit may be h „ to a statement by the
'' this Signature,that a satisfacto r -rtificate of death,having
been' w ,as required by law,permissi•r =granted to inter,remove
or die o-., of*lie body,stating the .age,sex,cause of death,
and o •; , details,Upon the form pr.- ` ed by the commissioner
of hea1i'
§ 3$ , AO, Na-person in charge any premises on which
intcrmem $ ations.are Made shall inter or ".,it the interment or other
dis .Body unless it is'accom �•y a burial, cremation or
transit herein ded. Stich person r endorse upon the permit,
the-, .ent, or c emation,over his si me, and shall return all
tier is�^ d to,., aregistrar of his distric ` thin seven days from the
date of i ism ot,cre l pon. Ile shall-keep/N.,"ord of all bodies interred
or other rf d_of-oil-the premises under hi ,arge,in each case stating
the p % deceirsetit'nerson,;place of;deat a ate of burial or disposal,
ddress Of the undertaker; whit L' •rd Shall at all times be
open'r t. inspect{ a.-Pro�d that-the ;-rtaker or person having
charge o a , et:htfying a body in , -..etery or burial ground
' having no iit ch shall si the bu 'l.r removal permit, giving
, the date of t" d to$cross the fact , he permit the words,"No
t with.
i . =i or 'permit within three days
i w ich the :erg is located.
" , , ( RS the' lava elative to the re-
lid,O ' ' a . a ' "" °., i irk a'r *r n3 SE DOLLARSThe NOR
law
will:b , , ` ' r �, ,'Are un rt penalty, t report
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