Leavus, Thurlow 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 City) in which the death occurred after the FILING and acceptance of aCOR-
RECT AND`C NIT CERT CATE OF DEAT , LEGIBLY WRITTEN IN DU• ,,:LE BLACK INK.
Dist.No.\ it Re lred No
County__-_____ pte of Dea / . Q
lag-,ar City - Sex _._ r Age_---/__ Yrs. Co or__ ___ _ _
(Cross out naives not app' abl (Or os.) -
Cause of Dea llr e"T.1 7
Place of Bu
! Cemf B r
(or Removal) • to 91 f
A CERTIFICATE OF DEATH of___
(Give full name of dec a )
having been presented to me containing the above stated particulars,and, after careful examination,
the same appe ring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I ha cce: ed the same for egistra '+n, have -corded it in my ocal Record with
the ab atd/egistered N il,and, the bast hereof I H GRANT ERMI
to = °
i 1
ame of � ---
,� (Ad ess)
the. to e bod
(Und: :ker or person ha charge of core) (Int:!e e or erw' spo to h w y
Dated /
191 (Signed r
Local Registrar
#11is Pe mit is su- dent for the Removal (and Interment or Cremation)of a body to any part of the
State subject to local ce'etery or other regulations), provided,that where removal is by common carrier,
the above Permit must a included in the Transit Permit.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
M TS OR CREMATIO S ARE MADE
Date of 114 L tgx-
(In merit or cr ti )
(Signed)
(Person 11
in charge)
(Name of Cemetery,Crematorium,etc.)
Person in charge must return this Permit to Registrar of his istrict 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 1s,located.
EXTRACTS FROM LAWS OF xgt3,CHAPTER 61g,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 shall attach the removal
permit to the box containing the corpse, when shipped by any transportation
company; said permit aeeonapmry--t e T>n to ite-depr6anation, wlrere,if
within the state of Nework,it shall be delivered to thg person in charge
of the place of burial. 7 k
§ 380. Duties of tidertakers; interment within the state. If the inter-
ment,or other dispositi ycf the body is to be made within the state,the word-
ing of the burial or reval permit may be limited to a statement by the
registrar,and over his Mature,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'he body, stating the name, age, se cause of death,
and other necessary det'ils upon the' form prescribed by th commissioner of
health.
§ 381. Interments. No person in charge of any pimises on which
interments or crematio are made shall inter or permit the Ynterment or otner
disposition of any bod ,unless it is accompanied by a b iial, cremation or
transit permit,as herei provided. Such person shall endors upon the permit,
the date of interment, it cremation, over his signature,an shall return all
permits so endorsed to ue registrar of his district within seven days from the
date of interment or cr ation. He shall keep a record of 411 bodies interred
or otherwise disposed o on the premises under his charge,i each case stating
the name of each dece ed person, place of death, date offarial or disposal,
and name and address f the undertaker; which record sha 1 at all times be
open to official inspect , provided that the undertaker or person having
charge of the corpse, den burying a body in a cemetery or burial ground
having no person in arge, shall sign the burial or removal permit, giving
the date of burial,and tall write across the face of the permii. the words,"No
person in charge,"and le the burial or removal permit within three days with
the registrar of the dist let in which the cemetery is located.
i SEXTONS an UNDERTAKERS violating the law relative to the re-
turn of permits are lialile to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Locar Registrars,are required,under'penalty,to report
violations thereof.