Van Husen, Sarah Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q;•" 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 aCOR-
RECT AND C P EETE ERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No. 0V Regi red No.
County - -- ---- -- Date o Death ' ....Li'- .......
1T�4 ow,,er,Vil LYr . Color
12 ,,nr City-. .._.... .Sex- -- Age__---
(Cross out names no ap is )
r Mos.)
Cause of De -
Place of Burt a e f anal /
(or Remover s }
A CERTIFICATE OF DEATH of . - -. S/(.dr-...- GL -
(Give full name of decease )
having been presented to me containing the above stated rticulars,and,after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for reg' tration, have ecorded it in my Local Record with
th ve sat d Registers r ber, d on t e bas of I HERE77NT�A .MIT
e of Unde
e to the ` Y.
(Un' er or person g c arge o cgips) ( er, ye, ^ s of[state
Dated .,,.' - IgI ..� (Signeda.�.... ^.
cal Registrar
Th:a Per is sticient for the Removal (and Interment o rema r f a body to any part of the
State (subject ocal cemetery or other regulations), provided,t t where r oval is by common carrier,
the above Permi must be included in the Transit Permit.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of re/
(Interment or cremation)
(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 r9r3,CHAPTER+tiiy,ARTICLE so.
§ 378. 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 hy 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-
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 outer
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. I-Ie 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 hiving
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 buriel,.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;as located.
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,udder penalty,to report 4
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