Reed, Mary Form VS No.s1 NEW YORK
STATE DEPARTMENT OF HEALTH
Jri.B11NY'
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar.(Deputy or Sgbregistrar)of the Primary Registra-
tion District(Talon,Village,or City)in which the death occurred after the FILING and of a COW.
RECT AN• s. CERTIFICATE OF DEJATII,LEGIBLY WRITTEN IN DURABLE CK INK.
Dist.No.... 1.1f. R red “.-
County .,-...--. • Date of Death........, `2' 3.1
`yam ... ..I .
lager or C •-- _ Age!lb _. Yrs. Color.. lAa.Ai�:_
(Cross out names not applicabl.\ /.J s (Or Mos.)
cruise.of Death... . ' ! ---._.---
Place of Burial i me - B Igt :.
for Removal) "- -. . ter -M• aido
A CERTIFICATE OF DEATH of '
• 've foil name of deceased) ---
having been presented to me containing the above Ste culars,and,after careful examination
the same appearing to be COMPLETE,CORRECT, AN ATISFACTORY AS REQUIRED BY
LAW,I have accepted the same for registration, have recorded it in my Local Record wft}a :.
hove eta egistered Nt m ,and on the basis therf I GRANT A PERMIT
(Name• ndertak
the.--._ r- - --• ----t l. I.
(U or h `charge RI rpse) (Inter. ,or •PR the
Dated-----•_- _ I. ,. _i9.7:. (Signed).-
Local Registrar
This Permit is sufficient for the Removal(end Interment or Cremation)of a bo4 to any • he
ggrtaate (sub) to beat osaistery or other r.guiattoask, provided,that where removal.is Dearman carriers
'the above Permit must be included in the Transit Permit.
ENDORSEMENT:..OF SEXTON OR PERSON IN
CHARGE OP PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of .1. ...... " zeal'
. - N cremation)
(Signed)--- j�►�
(Person '.. t---- _
. .
k charge).. (Name of' �ry,Cryom�arinm,etc.)
Person is charge must return this Permit to Registrar of his District within
SEVEN(y)DAYS from above data 11 no person Is ifl charge,the UNDER-
TAKER MUST SIGN ABOVE STATEMENT,write across the tete of the Permit
the words"No person in charge?and PILE PERMIT WITHIN THREE(3)
DAYS with Registrar of District in which cemetery)a loathed.
EXTRACTS FROM LAWS OF rug,CHAPTER 619,ARTICLE so.
;37A. 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
dohver 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 containingthe corpse when shipped by any trer►eportatina
mmgany; said,pamie-to aamaaspaner -ep. deeNastrem wharf;k•-
within the state of New York,it delivered lei the person in charge
of the place of burial.
t ;NM0. Duties of undertakers; !Tent• the state. If the iner►
sent or other disposition of the body
made within the the word-
inn of the burial or removal permitbe nn%ted to a statementby the
registrar,and over his signature that a ipstisfactory certificate of sth,having
been filedpass with him,as required by lawn„g permission iisggranted to h remove
�other ne�ar'y otherwise of
upon the faint presccribed by' the o cation ot �of
331. Interments. No person In charge of any premises on which
interments or cremations are made pall, or the interment or other
disposition of any body unless it is named by a burial, cremation or
transit permit,as herein provided. =hall endorse upon the permit
the date of interment,or cremation, s sgnature,and shall return all
permo endorsed to the registrar of within seven days from the
dateat
o.interment or cremation. He keep a record of all bodies interred
or otherwise of on the peens' under his charge,in each case sts
iv
the name of each deceased period placedeath, date of burial or
and name sill address of the ; which record shall at all
open to official inspection. providedthe undertaker or having
charge of the corpse,when burying a y in a cemetery or burial ground
having no in charge,shall., the burial or removal permit giving
the date of burial,and shall write the face of the permit the words,' No
person in charge,"and file the burial ptemoval permit within three days with
the registrar of the district in which thee cemetery s located.
ifs-SEXTONS and>71rDERT haw relent to the ro-
tors of are liable to a peneNOT THAN FIVE DOLLARS
Is well
e• MOREeTHA Local R ere N FIFTY FOR ,F�Tr ,E. The
to report
-• tlolatione thereof.