Pelkey, Almeda Form VS No.sl NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tion�D trio Permits Trwn can
a signedVillage, Ci only by the Local Registrar(Deputy or Subregistrar)of the Primary Registra..
RECT AND OPLETE CERTIFICATE OF in ich the DEATH,LEGath IBLY WRITTEN IN after the ILING DURABLEBBLACK INKaCOR-
Dist. No / Regist ed o..
County sate of D . _. .»
own,Vil-
Y (Ig1go ity « " SeCJs. a --- _ __ rs. Color. _(Cross out names n 'cable) (Or osJ
Cause of D ath.. ),..9..„
Place of B ri Ate J
or Remo 1 Ce 19=f
( at f B
A CER TE OF D _-- _ _. __ _
(Give name of deceased)
having been presented to me containing the above stated par lars,and,after ca examination,
the same appearing to be COMPLETE, CORRECT, AND S ISFACTORY A QUIRED BY
LAW,I ha4e accepte• the s e for registration, have recorded it in my L I Record with
the stated • = urn and o he basis r I HEREB PERMIT
to _
' •
r�K
(Undertaker or person havi c arge of o se) remove,or otherwise d1 s o ' e Y.
� c - •-- °
Dated.«... 4 (Signe
Local strar
Th:z Armit is sufficient for the Removal (and Interment or Cre�i ion)of a body to any part of t
State (subject to local cemetery or other regulations), provided,that WFtbre removal is b
the above Permit must be included in the Transit Permit. (� Y common carrier.
b-Z3-L*-8,vvv t&a-iubeo/
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
•
Date re
n is r cremation)
(Signed)
('Person n r r
m charger,!
(Name of Cemetery, rem+ rium,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 xg13,CHAPTER 6xg,ARTICLE so.
§ 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 orner
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 ofburial 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.
§20-SEXTONS and UNDERTAKERS violating the law relative to the re--
turn of permits are liable,to a penalty of NOT LESS THAN RIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars,are required,under penalty,to report