Hall, Ann NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
A-Si-This Permit can be signed only by the Local Registrar(Deputy or Suhregistrar)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 OMPLET 'CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. 1 __ Re istered No.
County of Washington, to of Death___ 2..1�- / .19a...�J
Town of Fort Edward. Sex:"- Age 5 Yrs. Color_�.-z S•
—
or Mos.
Village of Fort Ed
Cause of Death 7� ' y / -- ---- - 4,-0‘'L-C7---•
Place of Burial S,_— Cem ,�fi f GA ��l �-D
(or Removal) "" tee 7 "� _Date of Burial 19--
A CERTIFICATE OF DEATH of_Z_'?l�__ --
Give full name of deceased)
having been presented to me containing the above stated particulars, and, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT AND SATISFACTORY AS RE-
QUIRED BY LAW, I have accepted the same for registration, have recorded it in my Local
Record with the ve s ted Register Number nd on basis the HERE GRANT
A PERMIT to _� 1 ;s24' �� �
Name of Undertaker fJ Address
the " —e"f—�--- =the b dy
(Undertaker or person having charge of corpse) (Inter,remove,or otherwise er dis tate how])
Dated / 19 v Signed �`
- Local Reg' "
This Permit is sufficient for the Removal(and Interment or Cremation)of a body to any part of the State(sub-
ject 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 interments or Cremations
Are Made.
Date of__ -tiltryr."716 _. 19_�a
(Interment or Cremation)
Signed--AllfrjejegA4. `�.
(Person in Charge)-__ _ - -_
(Name of enretery, ematorrum,etc.)
Person in charge must return this Permit to Registrar of his District
within SEVEN (7) DAYS from above.late. If no person is in charge,the
UNDERTAKER MUST SIGN ABOVE STATEMENT, write across the face
of the Permit the Words,"No person in charge,"and FILE PERMIT WITH-
IN THREE (3) DAYS with Registrar of District in which Cemetery is located.
EXTRACTS FROM LAWS OF 19t3, CHAPTER 619, 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 regis-
trar of the district in which the death occurred and obtain a burial or re-
moval permit prior to any disposition if the body. ' * s The undertaker
shall deliver the burial permit to the Berson in charge of the place of burial
before interring or otherwise disposiig of the body; or shall attach the re-
moval permit to the box containing the corpse, when shipped by any trans-
portation company; said permit to accompany the corpse to its destination,
where,if within the State of New York,it shall he delivered to the person in
charge of the place of burial.
380. Duties of Undertakers; Interment Within the State. If the in-
terment,or other disposition of the body is to he made within the state,the
wording 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 in-
terments or cremations are made shall inter or permit the interment or
other disposition of any body unless it is accompanied by a burial, creama-
lion 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 withing seven
days of the date Hof 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 eachdeceased 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 having no person ill charge, shall sign the burial or re-
moval 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 per-
mit within three days with the registrar of the district in which the cemetery
is located.
--SEXTONS and UNDERTAKERS violating the law relative to the
return of permits are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OF-
FENSE. The law will .. '•iforced: Local Registrars,are required, under
penalty,to report violations the, of.