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Rood, Clara Form VS No.81 NEW YORK STATE DEPARTMENT OF HEALTH ALBANY OFFICIAL BURIAL (OR REMOVAL) PERMIT D This Permit can be Village,signed which o a Registrare occurred after FILING AND (Town in by the Local ecoccurred (Deputy or the andof theepanc COMPLETE CERTIFICATE OF DEATH, LEG BLY WRITTEN IN DURABLE BLACK INK. acceptance Primary Registra- tionDLSt•NO.-�� P ance of a COR- County-..-__- .. ........... Regis red No.............. Town, Vil_ Dfie of Death...-........... .....4 lage,or City--- - - - .. __ _ G' 912(Cress out n� ""-" Sex:.. / names not applicable) Age- - --- Yrs. Cause of Death_- • -_.. Color_.. ___- ( r s.) Place of Burial (or Rcmov • _._._. - - -- te.. 5 A CERTIFICATE O a y Bu&,:eits.....r.s. DEATH of • 12� .. having been presented to me containing the above stated particulars,and, after careful examination' the same appearing to be COMPLETE, (Give full name of deceased) LAW,I have cep to d e C same Tor r •CORRECT, AND SATISFACTORY AS'RE the ab s d Register- . Nu • stratio:r, have recorded it in REQUIRED th •, don the •a-'s thereof I - _ Local Record 4 to /// Under 4'e the (Un. -1� I (A.. _...� orierson ha charge of �----(In fp- / y. Dated._ /��__ _ - .......... 7Signed I dispose of This Per �'�= i is sufficient for the Removal (andInterme v State (subject t'State Perini ..cal cemetery or other regulations), o 1 Registrar ust be included in the 1 Provided, that a body to y part of the Transit Permit, ere remo is by common carrier. ;3-18-25,000(21-16523) DORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTER- MENTS OR CRE AT ONS ARE MADE Date of _...[ :11.:.... . !•Cs5'"'4 ? 9 1 (In ent cremation) (Signed).... �-V—. ces( . l/ 10.7 t .c (P er so _< ,. n - . r c (Name of Cemetery,cs(iatorium,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 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 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 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 barge 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 pr removal permit within three days with the registrar of the district in which the cemetery is located. SEXTONS and IINDERTABERS violating the law relative to the re- turn of hermits are liable to a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. Ti m law Will be enforced. Local Registrars,are required,under penalty,to+repent violations thereof.