Butterfield, Oliver Form VS No.61. 1-18-29-75,000(17-4366)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Age'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 Registered No
County " + Date of Deat/h..... ig. �
Town,Vi1--.f el Ie qs fall Y Sex.lK-__ *6
.... _ Yrs. Color
)age,or City age..__ ._ .._
(If city,give street address) (Or Mos.)
Cause of Death _----.--..-- . _.._...__.
Place of Burial(or Removal)_._....._.._...
Cemetery __- -_ Date of Burial 19
„..,Certificate of Death of.. -.-- _..----1"4. ---_ ..
(Give full name of d sed)
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 ululper,and on the basis thereof I HEREBY GRANT A PERMIT
to Tr ChDili/
(Name of undertaker) -, -
(Address) '
the -- =1...4...4 to the body.
(Undertaker or person wing charge of corpse) (In ov otherwise dispose of[state how)
Dated .i 19. /
. (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). unless reruneel::h„ ...,"^,-.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of
(Interment or cremation)
(Signed). —
(Person
in charge).— ,- — —
(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)
PAYS with Registrar of District in Which cemetery is located.
EXTRACTS OF THE VITAL STATISTICS LAW
§ 379. Duties of undertaker. In each case the undertaker, or person
having charge of the corpse,shall file he certificate of death with the registrar
of the district in which the death ccurred and obtain a burial or removal
permit prior to any disposition of tie body. * * * The undertaker shall
deliver the burial permit to the pers.n in charge of the pla,ce of burial,before
(;
interring or otherwise disposing of the body; or shall attach the removal)
permit to the box containing the co se,when shipped by any transportation
company; said permit to accompaly the corpse to its destination, where if
v'.......the ;;Late of New York,it s...111 be denvered 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. 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 cf his district within seven days from the
date of interment or cremation. He r.hall keep a record of all bodies interred
or otherwise disposed of on the premites under his charge,in each case stating
the name of each deceased person,pace 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 i., 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 acrd is the face of the permit the words "No
person in charge,"and file the burial 3f removal permit within three days with
the registrar of the district in which ihe cemetery is located.
re"'SEXTONS and UNDERTAKSRS violating the law relative to the re-
turn of permits are liable to a penalt of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Resistors,are required,under penalty,to report
violations thereof.