Rogers, Carrie Form VS No.61
NEW YORIC
STATE DEPARTMENT OF HEALTH
ALBANy
ia
OFFICIAL BURIAL (OR REMOVAL) PERMIT
O This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of t
tigvn District (Town, Village, or City) in which the death occurred after theg ) he Primary of
a Ct COR-
RECT OF DEATH, LEG_BLY FILING and acceptance
Dist.No... __ _,} O WRITTEN IN DURABLE BLACK INK.aCOR_
County Regi ered No.................
ri, z. . . Date of Death-(-- • ... 5" ----i9.""
/ „t
(Coos out names not app' b Se-"_�A q� - olork42 1[
ge -L- Yrs
Cause$ Beath s
(or Mo.)
Place of Burial
r
Place
Removal) 1a, _ Ceme- -- s41, .. .--..
As
c tery , f- t- 'teof 'aria!.......... __ao .
A CERTIFICATE OF DEATI T of____ 9
1t.A •
(Give full name of decease
having been presented to me containing the above stated particulars,and,after careful examination,
the same appearing to be COMPLETE,
LAW,I have accepted the same for registration, have recorded i n AS Local
the above ted Registered Number,and on the►aasis thereof I HEREBY GRANT QAIPERMIT
my Record with
to
16 ame of Under akle�J9
the t,
.. ,till,. .
� dc +
(Unde (( s
er or person acing charge of corpse) a t0_ wis di
Dated-... t_the body.
} - y� �9 (Interemov or of erwis�drspose.pl[state how])
e d .
�y (Signed) .. _ Y
This Permitis sufficient for the RemovalLocal Registrar
State (subject to locals cemetery or other regulations),(and, Interment or Cremation)of a body to an
the above Permit must be included in the ) Provided,that where removal is by common part of
Transit Permit.
5-23-18-25,000(21-16523)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENNTS OR CREMATIONS ARE MADE
Date of
q t�
to eat o ton
(Stgned)--•�il'�jG � e ��
(Person •. 1 `..- � G
in charge) �1e(r
( ame of Cemetery,Cremators 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 rgr3,CHAPTER 64,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 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 removal
permit to the box 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.
§ 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.
big of the burial or removal permit may be limited to a statement by tha
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
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.
SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of cermits are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enfor:ad. Local Registrars,are required,under penalty,to report
,iniations thereof.