Rozell, Baby Girl Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
,
OFFICIAL BURIAL (OR REMOVAL) PERMIT .
M'''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..,� �.e Regist red No
County •- __ Date of Death ?
�3/ 191 �r
Town,Vil- i ,
lage, or Cit Sex ' Age Yrs. Color- .-.
(Or Mos.
(Cross out names not applicable) )
Cause of Death 1 c 1 vi r? ,a,----f6,1.ti ,
Place of Burial �.. Ceme-a4.•�`. •.. ate of Burial-
(or Removal) - ---- - -- - -- t I '-191
A CERTIFICATE OF DEATH of- Y --ib s� -
(Give full-flame of dece ed�'S )
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 above stated Registered Number,and on the basis thereof I HEREBY GRANT A PERMIT
(Name of derta4r) address)
the to the body.
(Undnt,`or or person hay' g charge o corpse) (Inter re e r.t•t,isee e how])
Dated. 19i.� (Signed) .t V -
Local Registrar
This Perm is sufficient for the Removal (and Interment or Cremation)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.
v
3-12-17-25,000(21-4256)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATION S ARE MADE
Date of.-...---.— :, { rgr..._._
- erment or Crcm w2tan)(Signed) -.
(Person
in charge)
(Name of Cemctcry,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his District 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 2o.
§ 379. Duties of undertaker. In leach 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 occ red and obtain a burial or removal
permit prior to any disposition of the dy. * * * The undertaker shall
deliver the burial permit to the person i '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 corpse to its destination, where, if
within the state of New York, it shall` delivered to the person in charge
of the place of burial.
§ 380. Duties of undertakers; inte trient within the state. If the inter-
ment,or other disposition of the ody i 'to be made within the state,the word-
ing-of the burial or removal permit m'y be limited to a statement by the
registrar, and over his signature,that a atisfactory certificate of death,having
been filed with him, as required by law,permission is granted to inter,remove
or dispose otherwise of the body, statin' the name, age, sex, cause of death,
and other necessary details upon the fo prescribed by the commissioner of
health.
§ 381. Interments. No person i 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 a. ompanied by a burial, cremation or
transit permit,as herein provided. Sue person shall endorse upon the permit,
the date of interment,or cremation, o-,r his signature, and shall return all
permits so endorsed to the registrar of 's district within seven days from the
date of interment or cremation. He sh. keep a record of all bodies interred
or otherwise disposed of on the premise. rider his charge,in each Case stating'
the name of each deceased person, pia&:.f death, date of burial or disposal,
and name and address of the undertak"; which record shall at all times be
open to official inspection, provided t t the undertaker or person having
charge of the corpse, when burying a ody in a cemetery or burial ground
having no person in charge, shall sic the burial or removal permit, giving.
the date of burial,and shall write acros- the face of the permit the words,"No
person in charge,"and file the burial o removal permit within three days with
the registrar of the district in which t cemetery is located.
SEXTONS and UNDERTAK a'S violating the law relative to the re-
turn of permits are liable to a penalty, f NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLA • FOR THE FIRST OFFENSE. The
law will be enforced. Local Registr: are required,under penalty,to report
violations thereof.