Mead, Dusty Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
CM"'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 COMPLS,TE C TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE'BLACK INK.
Dist.No. �.Z M i_ gistered No.
•
County S.--.ise- Date of Death.. .._ _ ). 19_.4,
Town,Vil- _ --_ -- Se --- Aae.--_.- ._ .-Yrs. Color
lage, or City ts.n.r�.. v J
(Cross out names t a Heal le) r .o •
Cause of Deat . 1OA..Q.,
Pla((orce of Removal)1 `� Vs_ �"d a -- - ate of Burial_ 1q_34
-A CERTIFICATE OF DEATH of
(Giv 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 Reg' ered Numb nd on the basis here I HEREBY GRANT A PERMIT
to j•}-u- �.�... — JA4 ,
(Na a of nd�rtak r) ddress)
the ^ to.... t e bod
n.� a or•er n ng charge of c rpse (Inter ove, dispos f[st ow]) y
Date. .. ,,� ... .. ( 19- (Signed)
l Local Registr ar
is Perm, is sufficient for the Removal (and Interment or Crem on)of a body to any par of the
State ( I.ject to local cemetery or other regulations), provided, that wh e removal is by common arrier,
the abo -Permit must be included in the Transit Permit.
1-28 75,000(21-3004)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-,
ME OR CREMATIONfS ARSE
Date of .�/mil x
ntc tion)
(Signed) —
(Person {/ e
in charge) CCC///- .......
(Na e of cynetery,Cremator' m,et .
Person in charge must return this permit to Registrar of his District within
SEVEN (7) DAYS front above date. I( no person is in charge,the UNDER-
TAKER MUST SIGN ABOVE STATE NT,write across the face of the Permit
the words"No person in charge,"an FILE PERMIT WITHIN THREE(3)
DAYS with Registrar of District in which cemetery is located.
EXTRACTS FROM LAWS OF x443,CHAPTER 6rg,ARTICLE 20.
§ 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 ofa body; or shall attach the removal
permit to the box containing the co, then 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 ody into 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 satiskctory certificate of death,having
been filed with him,as required.by law,permission is granted to inter,remove
or dispose otherwise of the body, sta, ng 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 premis under his charge,in each case stating
the name of each deceased person, plate of death, date of burial or disposal,
and name and address of the underta er; which record shall at all times be
open to official inspection, provided at the undertaker or person having
charge of the corpse, when burying a oSy 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 ok removal permit within three days with
the registrar of the district in which the cemetery is located.
SEXTONS and UNDERTAKERS violating the law re1 five to the re-
turn of permits are liable to a penalty-of NOT LESS THAN FVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST-O�$FFENSE. The
taw will be enforced. Local Registry ,are required,under penalty,to report