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Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
riP"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 a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No..LIA 2-- Registered No.
County — Date of Death PIA-- i9iga.
.v
._.v..
—. Sex_i _ .. Age Z-3 Yrs. Color 1.,....
lage, or City
(Cross out names not applicable)_, _ (Or Mos.)
Cause of Death V .r•syNeN..&-vs..— ins2,---
Place of Burial( - .. Ceme-0 or Removal) tery ‘.3.-Cik, -11€4..Date of Burial
N,y
A CERTIFICA E OF DEATH of 'D Kf,,,, \)••(Give full full name of deceased)
having been presented to me containing the above stated particulars,and,after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Record with
the above stated Registered Number,and on the basis thereof I HEREBY GRANT A PERMIT
to \%%. .,-.111.CIC<%&: : .,...--\\-N:-;
(Name of Undertaker)
sl.s.AZddress)
the " IA to the body.
(Undertaker or person having charge of corpse) (Interiergse pz",.. e e [s..tat,--1,-4)
Dated 1.91__• (Signed)..
jai/a c Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the
State (subject to local cemetery or other regulations), provided,that where removal is by common carrier,
the above Permit must be included in the Transit Permit.
I
2-18-18-25,000(21-14071)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of___....__._ 191
(Interment or cremation)
(Signed)
(Person
in charge)
(Name f Ceipetery,Crematorium,etc,)
Person in charge must return this Permit to Registrar of his District within
SEVEN(7)DAYS from above date. If ho 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 LAVLS.OF 1913,CHAPTER 619,ARTICLE ao.
§ 379. Duties of undept r. In each case the undertaker, or person
having charge of the corpse,sh e tlae certificate of death with the registrar
of the district in which the`'dea Otturred and obtain a burial or removal
permit prior to any disposition of tit body. * * * The undertaker shall
deliver the burial permit to the personii.charge of the place of burial, before
interring or otherwise disposing of tbie body; or shall attach the removal
permit to the boa containing the corpse,,when shipped by any transportation
company; 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. 6.
§ 380. Duties of undertakers; intgiuent within the state. If the inter-
ment,or other disposition of ttie,body is tp,be made within the state,the word-
ing.of the burial or removal peecmnit mty 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 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 a mpanied by a burial, cremation or
transit permit,as herein provided.; Su ¢erson shall endorse-upon the permit,
the date of interment,or cremation, q t his signature,and shall return all
permits so endorsed to the registrar of'.4tis`district within seven days from the
date of interment or.crematigyi, 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 deceased4tsson, place of death, date of burial or disposal,
and name and address of Ord undertaker;,which record shall at all times be
open to official inspection,• rovided that the undertaker or person having
charge of the corpse, when. i�ying a body, in a cemetery or burial ground
having no'person in charge e3hall 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"b al or removal permit within three.days with
the registrar of the district ii wh tt the cemetery is located.
1•
ice'SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a 17entlty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY!DcIM,ARS FOR THE FIRST OFFENSE. The
law will be enforced. Local:Registrars,are required,under penalty,to report
violations thereof.