Andrews, Nellie 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 COOMPPLFyTE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.0�4,; ( Registered No
County w - ate of Death--_ __ _ ` a-- ; :: 7'9.k_ eJf(QYrs. Color
lages.ex.City " ' (Or Mos.)
(Cross out names not applicably
Cause of Death /�_
Place of Burial L/f.G Ceme- ,./ �� Date f Burial -311 I 1.7
(or Removal) eerr�yj�' 9 /
A CERTIFICATE OF DEATH of_��`f "" — ' `•t�-C�t�4-- `L`ce ------ - '—
(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 REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Record with
the
`/1/above stated Registered Number,//�{ and on the ba/isDthereof 1 HE 1'-/yr-�B,YvGRANT A PERMIT
to •
YYYYYY ,
(Na e of U dress)
the- . __(,Q to_____________• _ -- the body.
( ertaker� � or person having charge of cor se) (Int r ov�Apor wise disp e of[slate how])
Dated.. IX.,S� '21.eb Igi__ (Signed)_- Z--
�I(( Local Registrar
is Permit is sufficient for the Re oval (and Interment o remat' n)of a body to any part of the
State (subject to local cemetery or other regulations), provided, th wher removal is by common carrier,
the above Permit must be included in the Transit Permit.
12.3045-25,000(21-13047)
. ,
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of -41 a)( 'gr.?
erment mation)
<Signed)._ leiC'.4f• % ,
' ..
in charge) ..
(Name of Cemetery.Crematorium,etc.)
Person in charge must return this Permit to Registrar of his District within
SEVEN (7) DAYS from above date. lf 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 619, ARTICLE zo.
§ 379. Duties of undertaker. In each case the undertaker, or nerson
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 tile body; or shall attach the removal
permit to the box containing the cornjg,when shipped by any transportation
company; said permit to accompan the corpse to its destination, where,if
within the state of New York, it shal I be delivered to the person in charge
of the place of burial.
§380. Duties of undertakers; interment within the state. If the inter-
ment,or other disposition of the body s 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 4 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 th form prescribed by the commissioner
of health.
§ 381, Interments. No person in charge of any premises on which
interments or cremations are made s linter or permit the interment or other
disposition of any body unless it is companied by a burial, cremation or
transit permit,as herein provided. S h person shall endorse upon the permit,
the date of interment, or cremation, ver his signature, and shall return all
permits so endorsed to the registrar o his district within seven days from the
date of interment or cremation. He hall keep a record of all bodies interred
1
or otherwise disposed of on the premi s 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.
§ ' SEXTONS 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.