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Ellsworth, Wilson Form VS No.61 NEW YORK STATE DEPARTMENT OF HEALTH ALBANY OFFICIAL BURIAL (OR REMOVAL) PERMIT Q 'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra- tion District (Tow Village, or City) in which the death occurred after the FILING and acceptance of a COR- RECT AND C LbI- CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Dist.No. Regist�. Countyt ,a? 24��61-'7 Zate of DeathTzTerrir4i ! 9 ..'' City"'" _ Se ` �, Age (or Yrs; Co r. (Cross out names no app° ble) f Cause of Deat Place of Buria Ce ' at o (or Removal) tery.1 Tallpgr A CERTIFICATE OF DEATH of (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 ha e a%cepted the same for registr on, have r' o• ed °.in my Loca Record with the abo ate.;'egistered -r, the basis ther ,•%/�EREBY G T A •'MIT , AP to i a..e. ',der - . r(•ddres• the_ I wo.W: to a-!- : so. . (Und- .-rson ha ng charge of c���LLL222���,,,e) (Intl, o e,or o i -rwise sposeo6,•a.. ,t) Dated f IgI- / (Signed)___ • / e�, ocal Registrar This • rmit is sufficient for the R oval (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. MA 12-20.15-26.000(21-130471 ENDORSEMT_NT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTER- MENT3 OR CREMATIONS ARE MADE Date of xgx (Interment or cremation) (Signed).__._ (Person in charge) (Name of Cemetery.Crematorium,etc.) Person in charg^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 1013, CHAPTER 6.0, ARTICLE 20. § 379. Dutiesjpf 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 pewit 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 cdntaining the corpse,when shipped by any transportation companyy; said periitit to accosgnpny the corpse to.. s:,dasuin'*k", whc'e it within?he state of New York, it shall 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 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 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.