Dean, Fletcher Form VS No.61. 1-20-30-75,000 (17-4302)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
irif.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 B6UI
Registt� d Nam.
County WarrenDate of Death. �:rj.a--1� 9� I
Town,Vil.Cj of Glens rails,
lage,or City Sex___ Age__lO_� Yrs. Color________-.
(If city,give street a s) (Or?tlosJ
Cause of Death
Place of Burial (or P emovala in ` " 7
Cemetery_12/_ ratal geitelADG µ-/' Rfreedi ate o urial �`s<LQ V 19 ,.
Certificate of Death of C � 1 7
(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 abppz�stat Re tered N m er,and on the basis,%'ereof HEREBY PERMIT ,
to ✓�
Name underta ) 'ddress) <
the__ - - - to e b dy.
( --rta person awing charge of cor se) (Int em otherwise :h
spore owl)
Dated • 19__-a (Signed)._ lithati -
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 removal is by common carrier. in which case a
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR C1�EMATIONS ARE MADE
- Date ot....._-._.. I..-. *� _ _ re Al
( ferment oo a tion) i
(Signed)
—
(Person
in charge) .
(Name of Cemc:cry;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 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 containing the corpse, when 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 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 inteiment 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 premises under his charge,in each case stating
the name of each $eceased person,place of death, date of burial or disposal,
and name and ad ess of the undertaker; which record shall at all times be
open to official ction; provided that the undertaker or person having
charge of the corp , when burying a body in a cemetery or burial ground
having no person ia,charge, shall sign the burial or removal permit, giving
the date of burial,Aril shall write across the face of the permit the words "No
person in charge,"afid file the burial or removal permit within three days with
the registrar of the district in which the cemetery is located.
ir'SEXTONS trod UNDERTAKERS violating the law relative to the re-
turn of permits are ligblh to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE T FIFTY DOLLARS FOR THE FIRST OFFENSE. The
lino will be enfor_. ,,Local Registrars,are required,under penalty,to report