Starks, Sarah Form VS No,sl NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
i., ` 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.6 63 I
• Re istered No.
Count
Town,Vil- Date of Death- - CLA-L / 191.2
lag,, or City Se
(Or Mos.)
x A e 6 2
(Cross out names not applicable) g Yrs. Color..e�-e!, t _
Cause of Death _ .5, G. d
Place of Burlal C p eon. Ceme-
(or Removal) °`"'�""' "� tery Date of Burial f,S 1914r.
A CERTIFICATE OF DEATH of S.-as.rt A /Pve full name of dcease )
having been presented to me containing the above stated particulars,and eaftercareful 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 stated Registered Number,and on the basis thereof I HEREBY GRANTA PERMIT
v
to Ar.t,. �c 44G -'S izl-t-. 0 f."Q -, - ....._.... .r
the -_l/t LaR..t dress)
(U dertal:er or person having charge of corpse) to the body.
(Inter,remove, r e 2 of(state how])
Dated awe.- / 19I_Ca (Signed) 71-t- �G$e
This Permit is sufficient for the Removal (and Interment or C emation)Pof a body to Registrar
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.
5-27-15-25,030(21-6893)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of .-- l 6 9r 0
(Interment or cremation)
(Signed)--
(Person
in charge) 419 z ( t✓?' �' 4,
e of Cemetery,Crematoriy�cJ r+'
Person in charge ust return this Permit to Registrar of hit District within
SEVEN (7) DAYS fro 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 1913, CHAPTER Sip, ARTICLE zo.
§ 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 N w York. it shall be delivered to the person in charge
of the place of buria +�
' § 380. Duties o'undertakers; interment within tife 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 hislsignature,that a satisfactory certifyrate 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, ages.sex,cause of death,
and other necessary details upon the form prescribed by the commissioner
of health.
§ 381. Intermenws. No person in charge of any premises on which
interments or cremations are made shall inter or permit tie interment or other
disposition of any body unless it is accompanied by a burial,- cremation or
transit permit,as herein provided. Such person shall en rse upon the permit,
the date of interment, or cremation,over his signature and shall return all
permits so endorsed o the registrar of his district with' 'seven days from the
date of interment or cremation. He shall keep a recor ' f all bodies interred
or otherwise disposed of on the premises under his chargE'in each case sta cing
the name of each deceased person,place Of death,date burial or disposal,
and name and address of the undertaker; which recordlshall 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 -ry or burial ground
having no person in,charge, shall sign tt a burial or re uoval permit, giving
the date of burial,and shall write across t e face of the -rmit the words,"No
person in charge," apd Ole the burial or removal pe 't within three days
with the registrar of"the district in which the cemetery located.
Z "SEXTONS and UNDERTAKERS violating the jaw relative to the re
turn of permits are liable to a penalty of NOT LESS THAN-2IVE DOLLARS NOR
MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law
will be enforced. ;Local Registrars are,required, und'nr penalty, to report
violations thereof. ,
I. .:L