Ricketts, Emma 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 Cit ) in which the death occurred after the FILING and acceptance of aCOR-
RECT AND CO ETE ERTIFI TE OF DEATH, LEGIBLY WRITTEN INN DReURABLE LACK INK.
/ /
Dist.No...........:.....Q-•--- -Val-el- ate of Death
County /
�iaor
Age rs. ... - - -
leaffrreerti- 4._
Sex t (Or os.)
Aga,-�r City
(Cross out names not app icable) D ............
� 191(-
Cause of Death. - ;.„ Z .
Place of Buria Cem a o Burial �`�
(or Removal) '
to 'OW,/
A CERTIFICATE OF DEATH of ( roe full name f deceased)
having been presented O PLETE,g theO above , AND particulars,end, yrL cl REQUIREDecord Y
ul examination,
the same appearing to be COMPLETE, CORRECT,on, I ecordesSATISFACTORY ASNT A PERMIT
LAW,I accepted the same for regist ®the basis EREBY
h
istered ber,a
the ab a ate./'eg' ,......,
to
Name o i nderta:OW
-
to-
dre
- ••--------- (Inte m e,or
the-__-- - - havi arge o corpse) -
(Undert1 /J al
(Signed) Local egietrar
Dated - ......_ ----191---• ( g
of the
that where removal is yby common carrier,
This 'ermit is.•fficient for the Removal (and Interment or Cremation)of a body to any part
State (subject to loca f emetery or other regulations), provided,
the above Permit must be included in the Transit Permit.
12-30-15-25,000(21-13047)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
ME TS OR CREMATIONS ARE MADE
Date of /,'M 19r -
(I eat or crema n)
(Signed)..
(Person P � ••4.
in charge)._.
(Name of Cemetery,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his Dis ct 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 1913, CHAPTER 619, ARTICLE 20.
§ 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 sh 1 attach the removal
permit to the box containing the corpse,when shipped by any transportation
company.:....said_pggnit to accompany the corpse to i destination, where,if
within the state of New 'York, it&hall be delivered t the persoitria'-ehurge;----------;.:,q
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.
CV 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.