Wilkie, Martha Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR.REMOVAL) PERMIT
Pr'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-andacceptance of aCOR=
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No...5 IA Registered No
County �t .�L1tIIP ti. .._. „_... __.._... Date of Death__.alr f✓!� i9t 4
Town,Vit^ Sex.{ .- Age Q D
9 Yrs. Color_.Zr k
(Crosses not applicable _ N A (Or Mos.)
Cause of Death np fi
Place of Burial Q y Ceme- _Date of Burial )2—'r- 17 191_4
(or Removal) tery
A CERTIFICATE OF DEATH of Yi'! 0.
(GI full name of deceased)
having been presented to me containing the above stated particulars,and,after careful examination,
the same appearing to be COMPLE I E, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded-it in my kcal Record-with
the above
+stated Registered Number,and on the basis thereof HEREBY GRANT A PERMIT
to
(Name of Undertaker) (Address)
the '.!,-' "- to [..-3,, the body.
(Undertaker or person having charge of corpse) (Inter remov r ofkeryvis state how])
Dated ...crl. Z " ( i9i(2 (Signed
Local Registrar
This Permit is sufficient for the Removal (and Interment o Crematio 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.
111/11/11111
ENDOR'i MENT OF SEXTON QR PERSON IN
C. ' E OF PREMISES ON WHICH INTER-
M NTS OR CREMATIONS ARE MADE
Date of .... e /
(Interment or cremations`i
(Signed).__' __.ir
_., _..
(Person .
in charge)._.. i'e'Z4 440
i (Name of Cemetery, etc.)
Person ig charge must return this Permit to Reg trar of his District within
SEVEN;(7) 1 iYS from above date. If no person f in charge, the UNDER-
.
TAKER MV$T SIGN ABOVE STATEMENT,write across the face of the Permit
the words "Do person is charge," and FILE PEl IIT WITHIN THREE (3)
DAYS with'Registrar of District in which cemet q is located.
•
EXTRACTS FROM LAWS OF r913, CHAPTER 6r9,ARTICLE 20.
§ 379. Duties of undertaker. In each cast 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 andslabtain 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
within—the"
, co permit to accompany an , a attach the removal
�� �dq� any transportation
interring
th`e sfjew Y otherwise ork, it ny the drpseing of the body; r shall to etination,awhere,if
permit to the box containing the corpse,when sip ed by
or
n shaS
of the place of burial. peisou 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 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 file the burial or removal permit within three days
with the registrar of the district in which the cemetery is located,
Qom'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.