Middleton, Georgia es........,
Form VS No.61 NEW YORK
,A.
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Perrdit 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 COR-
REC5 AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
DistiNO... 61 0 i Registered No
County /(.1 . Date cf Death....22._,.....E.W. _4....2.
c,if-aa"
--rowir,-vii-
lage,u, City ex(F2111•Age 6—4/ Yrs. Color A/
(Cross out names not applicable)
Cause of Death_ a, (Or Mos.)
Place of Burialtai.4. . ,Aczeii.v. Ceme-
— e of Buri-I4d0____4___I9 22
(or Removal) - -
A CERTIFICATE OF DEATH of
(Give full name of deceased)
having been presented to me containing the ahoy tated 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 ab e stated Register4:Nu er,and on the basis thereof I HEREBY GRANT A ERMIT
- 4
a f Unde al..._..nt,r:A,116/2_<I
the to ddresg)---9/2-1 7"
the body
.,•
(Undent_tir or person having charge of coxps,e) (Int ove,or otl4ise clpo,- of[state
Dated 0
• -,Z ,‘ 19 ,-- (Signed)._
Local Registr
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part of the
State (subject to local cemetery or other regulations), provided,that where removal is by common carrier,
the above Permit must be Included in the Transit Permit.
9-8-20-75,000
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE 10F PREMISES ON WHICH INTER-
MENTS OR CREM iTIOISTS ARE MADE
Date of.._. � f �`.. .-. _
(I r ent ation)
(Signed)... ___. .. 44 _:..f r _
(Person y�
in charge)
ame of Cemetery, rematorium tc.)
Person in charge must return this Permit to Registrar of his District wiailiky
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 x9x3,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 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-
ingof 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
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.
•
Qom'SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS
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