Davis, Laurie -
Form VS No.61 - 2/so
NEW YORK �
STATE DEPARTMENT OF HEALTH i
ALBANY €
OFFICIAL BURIAL (OR REMOVAL) PERMIT ' y
y Registra
This(Town,can be, or City) in which the death occurredistrar of er the FI or LING and of acche eptance of a CORD
REDistrict (Town,Village, Y) LEGIBLY WRITTEN IN DURABLE BLACK INK.
RECT AND��O ETE CERTIFICATE OF DEATH, Regi ered No
Dist.No.,• / _ Ai �91
___ ate of Death 1
County - !
%d Yrs. Colo .___ -.-- ---
yjl_ Sex.- .t `age (or Mos.) l
-- 'tr City--
(Cross out names no plicable)
Cause of Death___
Place of Burial �p •
Cem e 'e f Burial__ f--�-- 91-
(or Removal) _��
A CERTIFICATE OF DEATH of..... .- ( 11 name of deceased)
having been presented to me containing the above stated pa
ulars,and,after careful examination,
CT
Y AS
BY
the same appearing to be COMPLETE, CORRECT,IAV Derecorded ISFA inRmy Local Record EDwith
LAW,I have accepted the same for registration,
the above st ted istered umber,and on t a is thereof REBY RANT• �A PENT
to... e pody.
(Name f Un ) ( ss)to
the.- _ (Inter, ove other dis os state how])
( r per ving char e of corpse)
t (Signed)._
-___191. Local Registrar
1�ed___ _ _... '"--•--" part of the
is Pe fff at where emoval body by common carrier,
t is sufficient for the R oval (and Interment remat )of a to any
State (subject t ocal cemetery or other regulations), provided,
th:: : : : us
bo Pemi mt be included in the Transit Permit.
r. 34) -
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of /7 191--jJ
nt ent or cremati x) `
(Signed) �..-
•
(Person
In charge)
(Name of Cemetery,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his&strict 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 xgx3, CHAPTER 6xg, ARTICLE ao.
§ 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 York, it shall be delivered to the person it. charge
. of the place of burial.
§ 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.
'SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a penalty of NOT LESS THAN EIVE 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.