Brower, Benjamin Form VS No.sI
NEW yORK
STATE DEPARTMENT OF HEALTH
OFFICIALALBANY
This permit can BURIAL (OR
tion District (Town, be signed onlyREMOVAL) PERMIT
-AND This
P E Village, or City) by the Local Re
in which thedeath
occurred
(Deputy or Subregistrar
Dist.No.. CERTIFICATE death occurred
S/ OF DEATH, LEGIBLY WRITTENrthe FILING)of the Primary Registra-
tion
IN DURABLEaccept of a COR-
RECT
County............ BLACK
Town, Vil- Regist ed ICw
No._
la e -�i'" - Date of De
pp Ah--
(Cross out City--
not a 4..... _ •---
Cause of Death__ "applicable) Age__, - •�9 c.
Se ".•_
Place o os)Yrs• Color.. ...
:-.
Burial �/n
l a Rein
A C __-
TIFICATE _�p
OF DEATH ter ate of
having been p of-- --------- "-�� -��� -_ . -- - (j _ �91�
resented to "
the same appearing me containing (Give fall name of deceased)
LAW,I haven re ted to COMPLETE,e aini CORabove stated `i.4J
CORRECT, Particulars " •---
theabove st same for registration and, after carful examination,
ed AND SATISFACTORY
�egisteredUmber have recorded it in AS REQUIRED BY
to............ .• nd on t e basis ereoE my Local Record
of U H REBY GR NT IIIrl
the_... - tak rn a , . c( PER IT
�� o haven �" (Address) -C-- b -
(U
Dated__...-� g charge of cor -- to_-_ y. ��
use
;i. :- 191
L4
)
(Inter,r v r•---_:_-
the b This Permit is ° Slb'ned)" _ e dis ose of[state )dY•
( of
State (subject to local cemetery
for the
how])
the above Permit Removal body
must be included in al (and IntermentLocal Registrar
•n h r regulations),ons)• Provided, that wheor re re f a -' er-•
1 -15-25, �+tti� move!is to any part of the
(1I10(21-1304� by common carrier,
i
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS MADE'
Date of .. r1 "A44. r"" ,� ,.p'r9r..
terment crem Lion)
(Signed)----. c
(Person
in charge)
(Name of Cemetery,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his D' 'et within
SEVEN (7) DAYS from above date. If no person is in charge, a UNDER-
TAKER MUST SIGN ABOVE-STATEMENT,write across the fac of the Permit
the words "No person in charge," and FILE PERMIT WITHIN THREE (3)
R DAYS with Registrar of Di3trict in which cemetery is located.
`+. EXTRACTS FROM LAWS OF 29r3, CHAPTER 629,ARTICLE 2o.
` § 379. Duties of undertaker. In each case the undertaker, or person
aving 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
VpNpermit to the box containing the corpse,when shipped by any transportation
ipmpany; said permit to accompany the corpse to its destination, where,if
within the state of New York, it shall be delivered to the person in charge
`? of the place of burial.
3 § 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
r Y registrar,and over his signature,that a satisfactory certificate of death,having
3 ..",been filed with him,as required by law,permission is granted to inter,remove
T-.at;dispose otherwise of the body,stating the name, age,sex,cause of death,
k. 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
I_ having no person in charge, shall sign the burial or removal permit, giving
J�j� 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.
PW"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
ORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law
'il be enforced. Local Registrars are required, under penalty, to report
violations thereof.