Evans, Olivia Form VS No. 61 NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I This permit can be signed only by the Local Registrar(Deputy or Subregistrar) of the Primary Registration
District(Town Village,or City)in which the death occurred after the FILING and acceptance of a CORRECT AND
COMPLETE CERTIFICATE/ OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No.J-(p._>," 1 Registered No.-
County.___„..Id..(rZ ..fecei,e' Date of Death....L!. .2,6- 1930.
Town, V11= e D `�, �'f
Loge, ox-�rCy. G7t .....r...-.L/u— Sex ....s.._.. Age 5 Yrs. Color ri�t/w
(If city give street addr s. • , . (Or Mos.)
Cause of Death.... .... ...... _..
Place of Burr eme- '
(or Remo ... ... ".: t -v . .................._....._....- D. e 'of Burial.2/I - 19a 0
A CERTIFICATE OF D ATH of... . ... ....„72.,l, —
(Give 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
7Registered
�Number,/ and on
on the basis, thereof I HEREBY GRANT A PERMIT
to.`2 I/0, C,11� c!'cu-1. tr(/. '�/�
ame of Undertaker) (Address)
the .n e . •.a ...-_to ..,. ........... the body.
(Uo*trt aker or pert n having charge of corpse) (Inter, re ,ve, o rtherwis ' pose of [state how])
Dated h.1. .-- /2,- 19. 0 (Signed
Local Registrar
This Permit is sufficient for the Removal (and Interment or ma nl 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 62) is required.
10-20-27-75,000 (17-2623)
ENDORSEMENT OF SEXTON OR PERSON IN
C ;ARGE OF PREMISES ON WHICH INTER-
OR CREMATIONS ARE MADE
Irate of tilleZ.,04116ff Ja ths,
Inter! ., ins ' n)
(Signed)
(Person
in charge)
(Name of Ceme Crematorium, etc.)
Person in charge must return tit. ' rmit to Registrar of his District
within SEVEN (7) DAYS from abov - If no person is in charge, the
UNDERTAKER MUST SIGN ABOVE EMENT, write across the face of
tt.e Permit the words "No person in a*e," and FILE PERMIT WITHIN
THREE (3) DAYS with Registrar of }strict in which cemetery is located.
SECTIONS OF TI-IF, 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 reg-
istrar 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 re-
moral permit to the box containing the corpse, when shipped by any trans- 's
.} _ A -e , paay..the.,ao se-to its destination,
w ere if within the state of New York, it shall be delivered to the person
in charge of the place of burial.
§ 310. 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
wording 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.
$ 981. Interments. No person in charge of any premises on which inter-
ments or cremati,us are made shall inter or permit the interment or other
d'sp sit ion 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 hie district within seven
days front the date of interment or cremation. He shall keep a record of all
boldies 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 Ole the burial or removal
permit within three days with the registrar of the district in which the
cemetery is located.
"SEXTONS and UNDERTAKERS violating the law relative to the return
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.