Gifford, George Form VS No.61 NEW Y9RK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR,REMOVAL) PERMIT
o'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 a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No. 45.g,2 Re jstered No 6•
County S 2,ra o. 3 19
• Date of Deat _ �ZfiLf J7
Town,V
•
Se;er£it O ,57 __ ;Sex Age.._l Yrs. Color . .Iet .
�..W^ (Or Mos)
(Cross out names not appy�e)
Cause of Death
Place of Burial Ceme-
.Date of Burial j
1 3 $
(or Removal) ' '' to 19_2_. •
A CERTIFICATE OF DEATH of �/ f 7_+ ((eon am deceased)
having been presented to me containing the above ated particular,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 abov stated egistered umber,and on b sis thereof I B GRAN A PERMIT
to ,� - - .t.-I�- _ �
(Name of Undertaker) (Address)
�T
the n 7.or 1a1 er to Inter the body.
(' taker or pe son havi charge of • We) (Inter,remove,or otherwise dispose of[state how])
Dated a/l�t •x 19_4Pa (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any 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.
r.
1-9-22-75,000(21-1608)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of r9-•-•--
(Interment ce cremation)
(Signed) 1 —.
(Person
ih charge) -
(Name of Cemetery,Crematorium,etc.)
Person in charge must return this permit to Reg'('atrar 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 i i3,CHAPTER 6re,ARTICLE ao.
§ 319. 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
�s}}��ta.ofNew York.it shall be delivered to the person in charge`dP liunal.
§880. Duties of undertakers; interment within the state. If the inter-
ment,or other disposition of the ody 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 hit 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 chary,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.
ice`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.