Scoville, Stephen Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
y'This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District (Town,Village, or C. y) in which the death occurred after the FILING and acceptance of a COR-
RECT AND C L$T CER F CATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.__!L( V ' / Regis N —
County a-4��L t . to of Deat 1_
tY_ S 4-,k ge rs. Co -- - -- -
ogerorei
(Cross out names not app• able) Mos.)
Cause of Deat
Place of Bur' 1 eme
(or Removal ter to B iii.1/ %- _ r
A CERTIFICATE OF DEATH of--- ----- {
(Give full name of eceased)
having been presented to me containin the ab e stated particulars,and,after careful examination,
the same appear' g to e COMPLETE, CORR T, AND SATISFACTORY S REQUIRED BY
LAW, I have cep the same for egistra ' n, have corded it in m ocal'Re ord with
the ahoy d gistered r, n the has' hereo GRA PE MIT
to
e of Und aker) (A ress)
the __ -_ _ to t ody.
n e pers n hajy n arge of c e) ( re ove, r se se o ow
Dated -f ica_ (Sign
oca Registrar A
This rmit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the
State (subje to local cemetery or other regulations), provided, that where removal is by common carrier,
the above Permit must be included in the Transit Permit.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
M S 04. REMATIONS ARE M
Date of a ip. .191
(ill. en t c r.asicspeetoe) i
(Signed) ..._ S
• .1.
in charge)
(Name of Cemetery,C-,ematori ,etc.)
Person in charge Must return this Permit to Registltai r of his District thin
om SEVEN (7) DAYS fr above date. If no person is charge,the U
ER-
TAKER MUST SIGN ABOVE STATEMENT,write across the face of th Permit
,
the words"No person in charge,"and FILE FERMI.;WITHIN THREE (3)
DAYS with Registrar of District in which cemetery is Ipicated.
•
EXTRACTS FROM LAWS OF 1913,CHAPTER iii9 ARTICLE 20.
§ 379. Duties 4f undertaker. In each case the,,undertaker, or person
having charge of the eorpse,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 otherwis disposing of the body; or shall attach the removal
permit to the box cdntaining the corpse, when shipped;by any transportation
company; said permit-to a-cc-cm-.-pany--the corpse to-its-destination, wisc•-er-if- ------
within the 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,
end 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 eemetery 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.
LW-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 r enalty,to report
riolations thereof.