Mead, Harvey Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gW 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. t..66 .1 1 Register d No.
County
Dak of Death .a44...- ii.,Z:zi/„...,t ". _ .... ..
Terorn7.3.41- fir
lagoa,..er City (O
(Cross out names not applicable) r .)2 _
Cause of Death,
Place of Burial Ceme-Mt ..
ate of B ial_ ..t -.7
_if//449_,T9/. __ _
(or Removal) Aytery
A CERTIFICATE OF DEATH of :Ps.. .
(G( lull name of deceas-.)
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 ated Re ' tere umbek and on the b ereof I EBY NT A PERMIT
f ertak
to •e a,taf, it • /17,
(Name o U 1_2._ (Actdress)
the to th body.
(Undertake r person havin c ge of cose) (Inter,r o o wis ' ose of[stat owl)
Dated 124.4 ,- _191.6
ry
(Signed). , ocal Registrar
Thi ermit is sufficient or the Removal (and Interment or Cre ation)of a body to any part of the
State (subj t to local cemetery or other regulations), provided,that where removal is by common carrier,
the above Permit must be included in the Transit Permit.
.....
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
M T OR CA ONS ARE MADE
Date
Date of 9.R w a...�..I.....__...s9r.�.
J�-!� Interment or ation)
(Signed).__.._..C..a. -r ! _. ».. ..._
(Person ii'e � u
in'large}._.. ..._.._
(Name of Cemetery.Crematorium,etc.)
Person in charge must return this Permit to Registrar of his District within
SEVEN (7) DAYS from above date. If no person is in charge, the UNDER-
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 r9t3, CHAPTER 6r9, ARTICLE so.
$ 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 3Tork.,-i4' },be-deliveseed,to,the person in charge
of the place of burial.
380. Defies of undertakers; laterment 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,pver 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 premi s under his charge,in each case stating
the name of each deceased person,pl�ce 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 short write across the face of the permit the words,"No
person in charge,,and rile the burial or removal permit within three days
with the registrar of the district in Which the cemetery is located.
SEXTONS and UNI7tIRT RS viola the law relative to the re-
turn of permits.are liable to a penalty of NOT LESS N FIVE'DOLLARS NOR
MORE THAN FIFTY DOLLARS FOR THE FIROFFENSE. The lam
will be enforced. Local Registrars are required,under penalty,to report
violations thereof.