Wallace, Ulysses Form VS No.61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
yr'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 ANDCON1PLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist.No.6 ca '' Regis ed No
County........ __. . __ •. _ ._......
ate of D th _- - caC d 1g_s ,
1ageTar C ity' Sex-- Age__ .Q Yrs. oIor.0. of
(Cross out names not ap e) (Or Mos.)
Cause ofy.th
Place e eme- &• .-Date of uria_ _ - .a.69_. 2
A CERTIFICA E OF DEATH of •--- - .
Give full name of deceased)
having been presented to me containing t e above state particulars,and,after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW,I •.ye accepted the sam Aagi.registration, ve recorded it in my Local Record with
the a .r; tated: Registered N' r,and on the a is thereof I HER Y GRANT
A .ER1tMIIT
m ofU, - ."
the---t,---- •- --- - - ' -• / .-e' to thebody
(U0 akert person tl��,,vin ar- of co se, (In obherw' is at ho
Dated-.. . a�. Ig ,7 (Sig ,
Local Registrar
is Permit is sufficient for the Removal (and I r o a ice)of a body to any part of the
State bject to local cemetery or other regulations), provi d that wherIremoval is by common carrier,
the above Permit must be included in the Transit Permit. '- J
10012t
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER—(
MENTS OR CREMATIONS ARE MADE
Date of 19-
(Interment or cremation)
(Signed) _
(Person ,7 /i
in charge) Le9.„L
(Name of Cemetery,Crematorium,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 1913,CHAPTER 619,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 shippedtpy,any transportation -_
company; said permit to accompany diel`earse I'd i dtsfinaTtiolf,i-vhere, it
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*ter-
2/lent,or other disposition of the body is to be made within the state,th ord-
iv
ing of the burial or removal permit may be limited to a statement y the
registrar,and over his signature,that a satisfactory certificate of deat 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 internen or other
disposition of any body unless it is accompanied by a burial,ore ation or
transit permit,as herein provided. Such person shall endorse uporo t se permit,
the date of interment,or cremation, over his signature,and shall eturn 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 cate stating
the name of each deceased person,place of death, daft of burial oalirrsal,
and name and address of the undertaker; which record shall at all i- es be
open to official inspection, provided that the undertaker or person:.liaving
charge of the corpse,when burying a body in a cemetery or burigl glf!5und
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.
10/17"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
[au;will be enforced. Local Registrars,are required,under.r enalty,to report