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Van Cott, Ellen Form VS No.61 ` NEW STATE DEPARTMENT MENT OF HEALTH OFFICIAL ALBANY tion D t,T.1Cts Permit can be si BURIAL (OR RE AND G T"wn a e fined only by the Local REMOVAL) RECT PLETE be ire ty� in which the Registrar(Deput ) PERMIT Dist•N w CATS OF death occ Y or Subre DEATH, LEGIBLY ed after 'URA L the Prim the FILING Count c� . WRITTEN IN DURAE d aoceotanoa oea Cp a- E ELACI{ INK I _ Regis (Cross Y ate of •............................ names not a Death Cause of Death-_ applicable) -•• Sex- ---- Place o __.-._ _ Age / Yrs. / / Buri (or 1Glos.j olor Cem (or Removal ---- •- A CERTIFICATE - OF DEATHr Date ofBurial...............____ _ ____________ having been °f• -..• Burial_• _ __ the sa Presented to .. -- -- -" - -- 91/_.-2/ II LAW, be e re e to be COMI LETS (Girtifull name and, after the . / { Pted the CO°above stated _�— sa RREC ParticularA and ) �� E-'�'o state me for re T, AND after careful examination, �c � red gistration, have recorded urination, t.-O. ber, nd on the AS REQUIRED BY basis t it in my Local Record (Name HEREB with the....... . e (Unde T erso RANT A p R Dated----•-- awing/c�harge o -__•__ ---------••--to.__ --- .... .... T This "-_191r'' �'i� (In - the above Pere to °CaI cemeter fficie t for the Re (Signed)._ •. °�Therwise dis o ody mit muss rmit is u included in the Removal. (and Interment ment or Cr✓en(n • al t- a y par of t� ansIt ided. that wh of a bodys ar `, `' Permit. to emoval ..by common..r ehe 10-24-18-50,000 (21-420) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTER- MENTS OR CREMATIONS ARE MADE Date of.._. -- / 7 f rgr__.... iZC R ( t ent!omatioa) (Signed) _L%-% _.¢_.L. .- Z-i1�`:'"/1.... (Person ' v j ----, / in charge). 'yC A LZtf.! .&:z t c. � a..L' �ua'i (Name of Cemetery,Crematorium, 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 1913,CHAPTER 6r9,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- 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 cremation. He shall keep a record of all bodies interred or otherwise disposed of ort.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. p'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,under penalty,to report violations thereof.