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Gilbert, Martha Form VirNo.61 NEW YORK STATE DEPARTMENT OF HEALTH ( ALBANY OFFICIAL BURIAL (OR REMOVAL) PERMIT Mi'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 COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Dist.No....`J 7 2-b Registered No County ` �� Date of Death .s ,a., 1 1' 19 Z 3 Town,Vil- l��A ll� )age, or City'' --•----_ Sex__A-.._. Age `l 0 Yrs. Colorer... (Cross out names not plicable) (Or Mos.) Cause of Death Place of Burial .l Ceme-Tl tx -'"''-"-a-*-+-T. ka. a Date of Burial_ .. ..rg�" (or Removal) ' "'"'""" tery CERTIFICATE OF DEATH of___...©_ O... a�n R.Y2,h� (Give full name of deceased) having been presented to me containing the above stated 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 above stated Registered Number,and on the basis thereof I HER BY GRANT PERMIT to (Nam f Under aker) (Address) the to the body. (Und` 1-er or person hav,erg charge of corpse) (Inter cmov rwise d}•epose o �s e howl) Dated ,c -k..c�-g..,_-1 �i i a..3 (Signed)"-" --. .. j - Local Registr.r This Permit is sufficient for the Removal (and Interment or Cremation)of a body to ariy part of the State (subject iu local cemetery or other regulations), provided,that where removal is by ceri,met carrier, the above Permit must be included in the Transit Permit. 1°-24-22-75,000(21-3064) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTER- ,, MEN S OR CRE AT O S ARE MADE 2-3 Date of I x9-._...- (Interment crem tion) ,/s it (Signed)-. '- _i- -�! (Person. "I in Chang.:) -i (Name of C etery,Crematorium,etc.) Person in charge must return thi Permit to Registrar of his District wi SEVEN(7)DAYS from above date. If no person is in charge,the UNDER- TAKER MUST SIGN ABOVE STAT ENT,write across the face of the Permit the words"No person in charge,"s d FILE PERMIT WITHIN THREE (3) DAYS with Registrar of District in w ich cemetery is located. EXTRACTS FROM LAWS OF 9x3,CHAPTER 6x9,ARTICLE so. § 379. Duties of undertaker. n each case the undertaker, or person having charge of the corpse,shall file t e certificate of death with the registrar of the district in which the death o curred and obtain a burial or removal permit prior to any disposition of th body. * * * The undertaker shall deliver the burial permit to the perso in charge of the place of burial, before interring or otherwise disposing of a body; or shall attach the removal permit to the box containing the cat ,vti egg ip d by nr�,y,,transportation _ .,c iep y me ttp fo5Its desfinanon, where,it --"`- �� ' f 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. $uch 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 front 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. lam"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.