Dunkley, Baby Boy No.61. 1-20-30-75.000(17-4362)
NEW YORK STATE DEPARTMENT or HEALTH
OFFICIAL BURIAL (OR.REMOVAL) PERMIT
b€TThis Permit can be signed only by the Local Registrar(Deputy or S isstrar)'of the PrhnartReglitat
tier District(Town,Villa or City)in which the after the FILING and of a COL.'
RECT AND COMPLETE CERTIFICATE _OF DEATH._LEGIBLY WRITTEN IN DURABLE SLACK INK.
Dist No. ...g
County.... _aJT!.____--.--._-....__ Date of Deatjt.. .. L
Town,Vil Gt .(tS kakis 1
�_. Sea. Age Yrs. Coiot
lage,or City :.: __..._.. _. a _..
(If city,give street: >•w• : (o►Mos.).
i
Cause of"Death—__ -_ . _.-• a - ---- •.. - --
44> a of Bari Removat t..3 - L it
4244.42...11
Cemetery.. ... ... .... D e Burk
Certiecate,of Death of_ ._ .. _ . ._.. .... . . , _.. . .:......
(Give f 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 have accepted a for registration,haves . •.edit in my Local Record with.
the ! ve stet usnb�er,and on the basis y- I HERF,# 'e C A PERMIT
•i 0_ f lfj
t�� .N,� fir ) .. /L. t
the. �!/,// I ,.
,i or pez �awag charge ) EIn
Dated.. I 1r'_...._ S� 19� _
(Signed). / 1 .lin'iiiir, $ / j• --f-
._ 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,ha which case a
Transit AarinitIVS N.. Osi to r....i—A
LSEMENT OF SEXTON OR PERSON IN
` LARGE OF PREMISES ON WHICH INTER-
.
OR CREMATIONS ARE MADE
Fat of r............. i9
t iter r cremation)
(Signed) _; .....
• 'a r
(Name o matorium,etc.)
Person in chard must return this Permit to Registrar of his District within
SEVEN(7)DAYS,•from above date. If no person is in charge,the WIDER-
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.
w.
EXTRACTS OF THE VITAL STATISTICS LAW
§ 379, Dirties of undertaker. In each case the undertaker, or person
having charge of the corpse,shall file the certificate of death with the registrar
p the
ctanhfoccurred andobtainsbutr removal
permit or to ydispositi n of * Tenderaker shall
deliver the burial permit to the person in charge of the place of burial, before
interring or otherwise disposing of their 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 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
ether necessary details upon the form prescribed by the commissioner of
5 381. 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 o& ie district within seven days from the
date of interment or cremation. He filsli 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 undertaken; 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 personin charge,shall sign a burial or removal permit,giving,
the date of buia,and shall write across the face of the permit the words ' No
person in charge,"and file the burial or val permit within three days with
the registrar of the district in which the etery is located.
Sirpermits
and UNDERTAKERS,vpiolating the law�relative to the re-
turn
OR�MORE THE liable
Do3LLLARSty f FORT TssHE FIRST FIVE DOLLARS
TA*
law rill be enforced. Local Registrars,eiiee required,under penalty,to report