Wilcox, Lutheria 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 Subrepiatr thePrimary Regiistra-
tion District (Town,Village, or City) in which the death occurred after the FILINGacceptance of*Mt-.
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No._...tf(p 0 f Register No
County IgA
Date of Death.- _ / �191
zz .
lager-or City - Seta Age Y rs. Color
(Cross out names not applicable) (or Moe.)
Ca tile of Death._ - -- -- • --
-
Place of Burial ��// eme- /
(or Removal) - fir tery -- -_Date �_-_ qi.f¢
A CERTIFICATE OF DEA H f _ _ . . A_._E,-___ _. .�_..
(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, AND SATISFACTORY AS REQIFiRED BY
LAW, I have accepted the same for registration, have recorded it in my Local Record with
the above t Re ' tere mbe ,and on thert reof I H Y A PERMIT
(Name of U ert (Address) -
the . -4efe. - to
(Un iert r erson vingphar a of co se) (Inter,rem v i 's}�se et is to howbody.
Dated J-__�____191-lo (Signed) __- _ ....
cal Registrar
This P it is sufficient for the Removal (and Interment or Cr tion)of a body to any part of the
State (subject o local cemetery or other regulations), provided,that wh e 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-
MENTS OR C TIONS ARE MADE
Date of /SOgiefookilosingreenoe4 id rgr
(Intern enr or •ation)
(Signed)._ir Li
(Person
in charge)
(Name of Ce ery,(rematorium,etc.)
Person in charge must re *titeranit to Registrar of his,District within
SEVEN (r) 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 zeta, CHAPTER 65e, ARTICLE ao.
I 37n„ 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, * * C 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 shall be delivered to the person in charge
of the place of burial.
§ 380, Duties of undertakers; interment within the state. tithe 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 dents 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 signatare, 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 tinder 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 file the burial or removal permit within three days
with the registrar of the district in which ther cemetery is located-
Vg"SEZ.TONS and UISDERI'AXERS vielatMg the law relative,to the re
turn of permitsere liable to a penally of NOT LESS TRAN2i.DOLLARS NOR
MORE THAN FIFTY DOLLARS FOR TIIE FIRST ERSE: The law
will be enforced. Local Registrars are required, penalty',,to report
violations thereof