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Kathcur, Charlotte Form VS No.61 NEW YORK STATE DEPARTMENT OF HEALTH ALBANY OFFICIAL BURIAL (OR REMOVAL) PERMIT VW-This Permit can be signed only by the Local Registrar(Deputy or Subregiatrar)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.___ ___O I Regist e No. County - ••••--•-•.•• /�/�'� to of Death._ Z-�['- � `—' I L. To-Am,Nil- i1f! /9 a� 1� i lag-,us City-- Sex.__.- _ A e_ icrs: Color____ __ . _ • (Crosse out names not applicable) Ms) Cause of Death o-- Place of Burial r�f� ; , i• ` CemeiP - �� (or Removal) '-; 4L _;_ t --•- -Date of Burial_.�( 1qi A CERTIFICATE OF DEATH of ___ (Give.full ifame of deceased)4 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 at is thereof I EREBY GRANT A PERMIT 7 )1'y(Nan to nd r (Address)f the to the dy. (Under p on aving charge of corpse) (Inter,rem v r e se of[state ]) Dated rgi_.4 (Signed)_-. ' f l Local Registrar This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local cemetery or other regulations), provided, that where removal is by common carrier, the above Permit must be included in the Transit Permit. ` 1 "-IL 5-87-15-25.000(81-6803) ENDORSEMENT OF SEXTON' OR PERSON IN CHARGE OF PREMISES ON WHICH INTER- S OR CREMATIONS ARE MADE Date of... s t' dr _.. ._? tor nterment or cremation) ...... ..... p (Person 20 in.harge). isietrontleasSo Vtit 1' ... _._... - .... .- (Name of Cemetery,Crematorium,etc.) Person in charge must return this Permit to Registrar of his District 'bun SEVEN (7) DAYS from above date. If no person is in charge, the UN R- 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 1914, 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 permit to the box containing the corpse,when shipped by any transportation company; said permit to accompany the corpse to its destination, where,if within the state of New York,it ell delivered to the Person in charge i of the place of burial. §380. Duties of undertakers; intermmnt 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,and over his signature,that a satisfactory certificate of death,having been filed with him,as required by law,neermission is granted to inter,remove or dispose otherwise of the body.statin the name,' age,sex,cause of death, and other necessary details upon the f�rm prescribed by the commissioner of health. § 381. Interments. No person a charge of any premises on which interments or cremations are made shall�nter or permit the interment or other disposition of any body unless it is mpanied by a burial, cremation or transit permit,as herein provi4ed. 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 premise (under his charge,in each case stating the name of each deceased person,pl of death,date of burial or disposal, and name and address of the undert { which record shall at all times be open to official inspection, provided P at the undertaker or Person having charge of the corpse, when burying a ody in a cemetery or burial ground having no person in charg , shall sign(the burial or removal permit, giving the date of burial,and shell write acrossthe face of the permit the words,"No person in charge," and file the butte or removal permit within three days with the registrar of the district in;w h the cemetery is located., Pir SEXTONS and IINI�ERT 3 viola a law relative to e re- turn of perm( a liable to a�naltyVol T LESS N FIVE DOLLARSrNOR MORE THANPIFTY NO RTHE FIR OFFENSE. The lase will be enfereed. Loea►l start are required, under penalty,to report violations thereof.