Brower, Charles Forrn VS No.6/
NEVV YORK
STATE DEPART1VIENT OF HEALTH
ALBANY
ThP OFFIC
lira-P (OR REMOVAL) PERMIT
eh_e
is errnit eln be si AL BURIAL
gned oynly.pbwyht ihehLtegal Registrar(Deputy or Subreg'strar) f .r.;
‘... L'NF CE F/CATE OF cDEATflIci,
c AZ;ti , Vlage, or Cit
iccurred after the PILING a:d tate r'nar3'Registra-
ePtance of a CDR-
L.L(.:1131.1'WRITTEN IN DURABLE BLACK imc.
Dist.No.. V I
. ..... ....... ....
Re • ed o............................
County................. ....._.........
...............
te of Death. .... ....... ...f......./..#47... if
............... ....................., r Sex .... ...f. Age. 4. 917rs. Co/or
Abge,..,Rt_city
(Cross out names not applicable).
Cause of Death__ .
. .. ....................... .
. .... .. .............. .
I
..............
Place of F3urial
... ... _............... Ceme-
- ate ria41444... . ___I9ri
(or Relnoval) ...... ...........
..tthtLoehh.A..a.e...v.V..a.
iV.n,A gv.eCh.b(..NaaE..pa.yR.mp..T.et..eIo.cr.fFd.ic.n t.IeR.ignCp..At.t
H
ee
Cn.-i st Odht tR-re-e r
theanpresented of........Ra.
t.biE•.
o.o.hC b.,sh.a.Aaa tv.N.e- .aSecirvAoteriTfeo.d.nu/
.4ei.Sll.a:d.F7nd.r.
a.A.r•n(Ce
a i ITonfdO d'R eacYr Yyt es GeArLd.R.).So.
-T'
(TJn
or erson hr;eue charge of c.j'ae)
ant , or,or ertv.
Dated .
..........19r i.
(Signed)...
--, ............f f 'r
.............:.......................................................................................This Permit is sufficient for the Removal (and Inter the
p rnent or Cremation)of a body tO n
State (subject to local eernet?ry or other regulations), rovided, that where removal is b anY-att°f
the above Pergrat tuust be inciuded in the Transit Pernik
3-12-17-25 000(21-4256)
ENDORSEMENT OF SEXTON OR PERSON I]v
CHARGE OF PREMISES ON WHICH INTER-
MENTSj OR CREMATIONS ARE MADE
:::
Af—e1C` _cant
r
(Person
in charge) �'�.,�
(Name of Cemetery,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his Dis t within
SEVEN(7)DAYS from above date. If no person is in charge,t 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 no.
§ 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
witki3the state of NA.w Y.nrk, 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 i,; 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.