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Maxwell, John 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 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. Or D I Register if No. County Da of Death J 191 z - d� g Se Age Color_.___ _a __- i lager er City ,rq,., (Cross out names not applicable) % J Cause of Death Place of Burial Ceme- ,q at :urial _ (or Removal) ' tery - ay __19I_i? A CERTIFICATE OF DE TH of - - - (Give full name of de ased) having been presented to me containing the .•• •• • stated particulars,and,after careful examination, the same appearing to be COMPLETE, CUR• T, AND SATISFACTORY AS REQUIRED BY LAW,I have accepted the same for registr- on, have recorded it in my Local Record with _ the-a Registe d Number,and onntthe bas' t reof I HE T A PFIRMIT Wi (Name of U ,erta•r,)__ dress) / the •.. t4!� - __ ' to .._2 1�1!� �• th- body. (Undertaker person having of co se) (Inter,remoiP. .r -pose of[stat- ow]) DatedL. e191_�j (Signed)--- - I•- ---4`'� '- '- ---'-- - - Local Registrar Thiif it is sufficient for the Removal (and Intermen or Crem,ion)of a body to any part of the State (sub- local cemetery or other regulations), provided,that where removal is by common carrier, the above • it must be included in the Transit Permit. i 5-27-15-25,000(21-6893) W 11111111111111 ENDORSEMENT OF SEXTON OR PERSON IN CHARGE op PREMISES ON WHICH INTER- NTS'.(OR CREMATIONS AB MADE Date of rgr.(-.! Interment o/emation) (Signed) ,e4. 4. ..,4 (Person . in charge)._ ,; --•-•- .:�,-, ,►"' •(Name ... of Cemetery.Crematorrtun,rete.) Person in charge'<:ust return this Permit to Registrar of his Die ct within SEVEN (q) DAYS above date. If no person is in harge, the UNDER- TAKER MUST SIGN`. t OVE STATEMENT,write across a face of the Permit the words "No Perms' in charge," and FILE PERMIT THREE (3) DAYS with Registrar,ofDistrict in which cemetery is ocated. EXTRACTS FRck LAWS OF egr3, CHAPTER de , ARTICLE 20. § 379. Duties '•• undertaker. In each case the ,dertaker, or person having charge of th; .rpse,shall file the certificate of. `•th with the registrar of the district in :, h the death occurred and obtai.(a burial or removal permit prior to any sposition of the body. * * * undertaker shall deliver the burial •, .it to the person in charge of the ce,ofburial,before interring or otherwi' disposing of the body; or shal attach the removal permit to the box co 'niag the corpse,when shipped any transportation company;om������y said •. i to accompany the corpse to its -tination, where,if o'f'thn,theeStag burl: • ij,bbslI b dg dLverg , _. .Peon in charge ,, .., § 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 any 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 res,ord of all bodies interred or otherwise disposed of on the premises under his chargC,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 ceme ery or burial ground having no person in charge, shall sign the burial or r oval permit,giving the date of burial,and shall write across the face of the it the words,"No person in charge," and fie the burial or removal pe it within three days with the registrar of the district in which the cemetery'is located. Or SEXTONS and UNDERTAKERS violating the law relative to the re- turn of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Registrars are required. under penalty, to report violations thereof.