Kingsley, Hannah Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1270-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._1f6 0 / Registe ed N
County �� - _l..`._.. Date Of Deal a i r 1q1
TDWu,V. 247L4 Sex_77/4.S. Age Zl[____Yrs. Color tif
lager 69'City - (Or Moe.)
(Cross out names not applicable)
Cause of Death
Place of'Burialj Ceme-
(oy Removal) tery ---Date o£ Bur al__� /-7_19i.L/
A CERTIFICATE OF DEATH of
(Give.full name of deceased
having been presented to me containing the above stated particulars,and,after areful e amination,
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 a t ed Regist ed N tuber,and on the si hereof I EB NT4 P MIT
(Name of U erta (Ad ess)
the ..4.444.. to t body.
(Undertaker o erso avi charge of coryse) (Inter,r m1 w• spose of[st e how]).,
Dated 191_4.• (Signed) t _.L_rrr.
Local Registrar
This Permit is sufficie 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.
t 5-27-15-25,000(21-6893)
ENDORSEMENT OF SEXTON OR P 0.RSON IN
CHARGE O PREM*$ SON IN ER-
ME�NTS ')R CREMATIONS ARE 0 E
r Lc Date of . —' LI .....;_...._... rgx,t....
(Interment or usertertea)
{Signed}.____....._..
4-CYfr��
(Person /�y1 in^large)..... G= t�./.... _ ....
,(N�+ ame of Cemetery,Crematorium,a .:)
Person in charge xdpst return this Permit to Registrar his District within
SEVEN (7) DAYS from above date. If no person is in „ ge,the UNDER-
TAKER MUST SIGN A1OtE STATEMENT,write across the face of the Permit
the words "No person In charge," and FILE PERMIT W HIN THREE (3)
DAYS with Registrar 40 District in which cemetery is I' ated.
EXTRACTS PROI ':LAWS OF xpx3, CHAPTER 619,p RTICLE so.
§ 379, Duties of dertaker. In each case the rtaker, or person
having charge of the coke,shall file the certificate of de with the registrar
of the district in which,the death occurred and obtain „`burial or removal
permit prior to any die ition of the body. * * * e undertaker shall
deliver the;burial perm to' the person in charge of the . ..a of burial,before
interring or otherwise "posing of the body; or shail""ttach the removal
permit to the box con ning She corpse,when shipped by any transportation
comneny; said permit' accom
of ee ice b uurr y e corpse to its stination, where,if
,Nl. '3'./.4.i sitalil.rYaiix persont4 in. argn».
ia
§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 statement by the
registrar,and over his signature,that a satisfactory certificate of death,having
been filed with him,as required by law,permission is granted to inter,remove
or dispose otherwise of the body,stating the name, age, sex,cause of death,
and other necessary details upon the form prescribed by the commissioner
of health.
§ 381. Interments. No person in charge of any premises on which
interments or cremations are made shall inter or permit the interment or other
disposition of auy body unless it is accompanied by a burial, cremation or
transit permit,as herein provided. 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 premises under his charge,in each case stating
the name of each deceased person,place of death,date of burial or disposal.
and name and address of the undertaker; which record shall at all times be
open to official inspection, provided that the undertaker or person having
charge of the corpse, when burying a body in a cemetery or burial ground
having no person in charge,shall sign the burial or removal permit,giving
the date of burial,and shall write across the face of the permit the words "No
person in charge," and 61e the burial or removal permit within threefdays
with the registrar of the district in which the cemetery is located. •
A
"SEXTONS and INDERTARERS violating the law relative to tte re.
a permits*seLESS
OAlatMORETHHNFFIFTY DOM-AIM ofOR THEI OFFENSE. The will be enforced. Local Registrars are required, under penalty,to repott
s violations thereof.