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Van Husen, Jacob Form VS No.61 NEW YORK STATE DEPARTMENT OF HEALTH ALBANY OFFICIAL BURIAL (OR REMOVAL) PERMIT 119-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 CPR.. RECT AND O P E ^ERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Dist, Noy County ���� / Registered No _ County �-e-'1 Date of Death -•_ Town,Vil- Pel-e-c19 e 'y 191age, or City Sex;I:I Q Age / 7 7 Color /-erfz (Cross out namelicable r Mos.) Cause of Death Place of Burial Ce (or Removal) -- - --- '''' •-7"---4 - _. t of u ' i A CERTIFICATE OF DEATH of Cep-___. havingbeen g (Give full name of dece sed) presented to me containing e 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 Regis red Number,and the basis th . f of I H EBY GRANT A PERMIT to /--12 ...���}}} meofU er �' the.1,��� xfi (Addre (Undertaker.or person ha to. �%' Ody. g charge of corpse) (Inter,r ve,or otherwi dis se of[state ow Dated A 4� � 19Jl.D (Signed). .._. �- 7---Local it This Permit is sufficient for the Removal (and Interment or Cremation)of a body toRegiyany part the ,�{j� State (subject to local cemetery or other regulations), provided, that where removal is by common carried.JJ the above Permit must be included in the Transit Permit. 8-22-19.75,000(21-1488, ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTER- MENTS OR CREMATIONS ARE MADE Date of x9 (Interment or cremation) (Signed) _.. , (Person in charge) (Name of Cemetery,Crematorium,etc.) Person in charge must return this Pe'" rto Registrar of his District within SEVEN(7) DAYS from above date. If sson 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) PAYS with Registrar of District in which cemetery is located. EXTRACTS FROM LAWS OF x913,CHAPTER 619,ARTICLE 2o. § 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 shal attach the removal permit to the box containing the corpse, when shipped '3y any transportation company; said weecinpanr4he.-corpse..to-itsstiostinattass,.,w are,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 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 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 crepation. 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 cemetery 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. ilie°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 lam mill be enforced. Local Registrars,are required,under penalty,to report violations thereof.