Potter, Mason Form VS No.sl NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra-
tion District (Town,Village,or ity) in which the death occurred after the FILING and acceptance of a COR-
RECT AND C LEJE CE T FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No. Q//f Regis d o.--"
County !.to of De.th___
�----te 2217
� / - - --- 91 -
-hII�,^,r City— �.._... Sex A•: G'
Y s. Color_- _-__ __ -
(Cross out names not plicabl ( / /�'�ri Mos.)
Cause of Deat
Place of Burial
eme_ r,.. ,f
y pra.414
i/� lyi
(or Removal) t
ive full name of dcease )
A CERTIFICATE OF DEATH of
having been presented to me containing the above stated(particular,and,e afterd careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW,I acc pted the same for re••stration, ave reco de it in my Local Record with
the ab at/Registered ber!nd on the .asis th HEREB G A P RMIT
to �;
me of U I, r- -, ---- -- -- Y ----
the i� j, / ,
Undert r rsovizier of c e to body
(Inter, mov or o rwis spos o
Dated �9 (Signed) Local
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an
art of th
State (subject to local cemetery or other regulations), provided,that where removal is y common carrier,
the above Permit must be included in the Transit Permit.
,....,
u
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of �---- 1 191g.
- sierra .. rrn)
(Signed)
(Person
in charge)
(Name of Cemetery,Crematorium,etc.)
Person in charge 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 1913,CHAPTER 619,ARTICLE ao.
§ 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 remmpQw,al rF
permit to the box containing the corpse, when shipped by any transportifition
company; said permits'to accompany the-corpse-to-its-giestinatierr-where, if--
within the Oate 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 ody 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 a interment or other
disposition of any body unless it is accompanied by a burial, cremation or
transit permit,as herein provided. Such person shall end se upon the permit,
the date of interment,or cremation, over his signature, end 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 cemet or burial ground
having no person in charge, shall sign the burial or r oval permit, giving
the date of burial,and shall write across the face of the it the words,"No
person in charge,"and file the burial or removal permit" thin three days with
the registrar of the district in which the cemetery is loc ed.
i" "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
notations thereof.