Lockhart, George Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Fi'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 aster the FILING and acceptance of aCOR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.--,�-_ j-Q-� Registered No
rCounty Date of Death- -.2.n�t. - .3
,t� Sexi Age_- -�/�/� rs. Color-..id% .
Iagoa,arClty"' .. (0 mo )
(Cross out names not apply")
Cause of Death _._ -_- ___ 4
Place of Burial Ceme-
(or Removal) ery _ �� al = /19 2 3
A CERTIFICATE OF DEATH of_ _
(Giv ull name of eceased)
having been presented to me containing the a ve stated pa culars,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 eta ed Register Num e)r,and the basis er f I HEREBY
/JGRANT q�/A PERMIT
„y. ,
Name of n Address)
the to._ t&ie body.
( ker or�person_havi charge of corpse) (Int ove,or erwis i ose of[sta ow))
Dated... �Cj� /U
1 19_%: (Signed).
Local istrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a oyany part of the
State (subject to local cemetery or other regulations). provided.that where removal is y common carrier,
the above Permit must be included in the Transit Permit.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of W4 44 -4(Z ' .9.z,3
,kInterment or cremation)
(Signed) 1 ,. —
(Person arge).# A...A.,04/411..‘c c 4....
in ch
, (Name of C etery,Crematorium,etc.)
Agg dreinust 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 64,ARTICLE 20.
§ 379. Duties of unilertaker. In each case the undertaker, or person
having charge of the corpa shall file the certificiate of death with the registrar
of the district in which .e death occurred and obtain a bu ial or removal
permit prior to any dis tion of the body. * * * The uidertaker shall
deliver the burial permit to the person in charge of the place Cf burial, before
interring or otherwise diosing 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 destiNition, where, if
within the state of New York,it shall be delivered ttr-the- rson 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.
IR?"'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
•notations thereof.