Duett, Carrie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ai'This Permit can be signed only by the Local Registrar(De ty or Subregistrar)of the Primary Registra-
tion District(Town,Via,or City)in which the death occurred after the FILING and wo.enaance of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE RI Awl INK.
Dist N
• o._. G egg_ R
County Warren�-7- tr.- ""Date of eath@g -�,�._- .I9/
Town,ViLity OT Glens-- .-;I ,
lags,or City-- ...... -_— . ._____ .a . --_ Age.. --Q._.Yrs. Color - ..-.
(If city,give street °S) gM
Cause of Destla . .......
Place of Burial emoval).. 1 idilteleip
/ '"._ '_-.
Cemetery---_--..*.. •- • -...-._ ___________Date of Burr 4
•
1 f
Certificate of Death of 4 -
(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 B'
LAW, k ve accepted same for registration,have recorded it in my Local Record with
the a- stated is II umber,and on the basis •, t�' I ° > -Y A,PERMIT
the. " 'fir r.40 — t
Dated ` it c t ) S• e(Inter
i/ 1/r i / i ,
_ ( > — Reps
trar
Permit is auffmient for the Rssnoraj (and Interment or Cremation)of a bod teeny of the
State (e jest to.local eatery or other regulations),unless remove/is by common ,In cam a
Trandt Parma NA lia.Ail i.neanzi.ad_
,_ ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
' Data.t_.:.. f�d� �f Mige
(Shoed)is charge)charge), of Cemetery, sxs + + '
Person hi charge must return deb,ii it to Registrar of his District within.
SEVEN(7)DAYS from above date. no person is in charge,the UNDER-
TAXER MUST SIGN ABOVE STATEMENT,write across the face of the Permit
the words"No person in charge,"sad FILE Pular WITH EN THREE(a)
PATS with Registrar of District in which cemetery'his located.
EXTRACTS OF THE VITAL STATISTICS LAW
a7a. Duties of undertaker. in each Cale the undertaker• or person,
having charge of the corpse shalt file the°ertificate of death with SOS
of the district in which the death occurred and obtain a burial or
permit prior to any dispositionof the body. • • o The undertaker e�h
deliver the burial permit to person in charge of the place of burial,before
interring or otherwise disposingof the body; or shal1 attach the remove/
permit to the boa,containing the corpse when.shipped by any potatt pi said permit to accompany the corpse to destinetionoshere if
Within Vass State of New York,it shall be delivered to the person is charge
M the platy of burial.
,880. Duties of _ lt�wiahet et ate. If tlh
smut,or other disposition of the body is to made within the state,the
bigot the burial or removal permit may, limited to a statement by the
registrar,and over his signature that a satisfactory certificate of death,having
been Med with him,ae required by law,permission.Is granted to intertremoVe
or dispose otherwise of the body, ting the name.ag , a,;cause of death,
and other necessary details upon thee•re
form prescribed by' thecommissioner el
healil a81. Interments. No person hi charge of any premises on which
interments or cremations are made shall inter or interment or other
disposition of any body unless it is accompanied �byy *non or.
transit permit,as herein provided. Such person shall a 1ipp�oonr�,� tt,,
the date of interment,or cremation over his signature,and shaII alt
permits so endorsed to the registrar ci his district within Seven days fr the
date of interment or cremation. Be shall keep a of all bodies Interred
or otherwise disposed of on the premises under his charge,in each cape meting
the name of each_deceased person,place of death,date of burial or dioPeaat
and name and address of the Uadirtaker; which icu.3 shall at all;times be
open to coal inspection; provided that the undertaker or
charge of corpse,when burying+;..body in a c 7aeter9 or�ri d
having no In charge,!ball eiga the burial or removal giving
the date of burial,l,and shall write the face of the permit the Nopers
the rei tregutrar of the�d Aled the
cemetery is removal permit within
three with
p'SEXTONS and VNDERT viola the law relative to the re*,
turn of Permits are liable to a f NOT LESS THAN DIVE DOLLARS
NOR MORE THAN FIFTY FOR 7DRST OFFENSE, Tie.
law will be snfereeJ. Lead Registrars,are required,under penalty,to report
detadens.thereof-