Rivett, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tire 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 RO PLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No..0 6_C / Regi ered No
County Warren __.. ,...Date of Death__ 17 19.2.,V
1 ge,leit of C f G�en�ns__Ea[[sy__N. Y._-_. Sex_.- Age___i_7 Yrs. Color__le
(If city,give street addre (Or Mos
Cause of Death
Place of Buri r Removal),______ h. If
Cemetery .i-!f.A.AJ �- Date of Buria . --...I? 190
Eertificate of Death of nearaA04. RAAtat
(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 ove s ated egis ed Number, rid on.the basis thereof EREBYDRANT A PERT
(N e of taker) (Address)
the to____ 044•14•1. the body.
( dertaker or person having charge of corpse) (Int , o , oth wi p se of[s )
Dated 4_q 19.21 (Signed)
Local Registrar
is 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 removal is by common carrier, in which case a
Transit Permit(VS No.62)is required.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS •R CREMATIONS ARE MADE
Date of._....._ .... • ._��_.._..._._...... _ _ rg.
~�emation �M._.�___ w-
(Signed) _ v c. a_ -. .i; ..--. ________-
(Person ', --
in charge) e 1.b kwesay
(Name of Cemetery,Crema •rium,etc.)
Person in charge must return this Permit to 'egistrar 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 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 containmg the corpse,when shipped by any transportation
company; said permit iss;,,accompany the corpse to its destination, where if
within te state of New- ork,it shall be delivered to the person in charge
of the place of burialvr'
§380. Duties a ers• interment With a state. If the inter
pleat,or other dispositi .e f he body is to be me thin the state,the word-
ing.of the burial or rc` permit may be lino a statement by the
registrar,and over his signatl that a satisfactory'certificate of death,having
been flied with him,as required by kiwi,ermi$sion is granted to inter,remove
or dispose otherwise of the body,staalftg the name, age,sex,cause of death,
and other necessary details upon the form prescribed by the commissioner of
health. _ -
§ 381. Interments. No persi4 c `e of any premises on which
interments or cremations are made: '_or permit the interment or other
disposition of any body unless it ied by a burial,cremation or
transit permit,as herein provided.3 tier, 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.
ow'SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a penalty of NOT LESS THAN FI'tE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
lam will be enforced. Local Registrars,are required,ander penalty,to report
violations thereof.