Doelcly, Mabel Form VS No.61. 1-20-30-75,000(17-4382)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT ear•This Permit can be signed only by the Local Registrar(Deputy or Subregistrar)of the Primary Rsglstra-,
tion District Town,Village,or City)in which the death occurred after the FILING and acceptance of a COR-
RECT AND ow TE TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist No. ..__.._ Registered No.
County..- .. .. .. ... .- - --_. Date of Death au" i d�
Town,Vil- r __ Age e7 1 Yrs. Color-....._.._--....
lager or City' ---- --.___-_
r .
(If city,give street address)
Cause of Death _.._•
r
Place of Burial(or R vat)-- `�._=- -- --__ C-4 __--_ _ _.._.-____ __ _�
Cemetery -— - le=! Date of Burial-- - ---- ---�°f---19- f
Certificate of Death of ` 41.4-1 A _...
(Give full name of deceased)
having been presented me containing the above stated particulars and, after careful examination
the same appearing to beCOMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY
LAW, I have accepted-the same for registration,have recorded it in my Local Record with
the abov ted Register Number don he basis there;, EEBY PERMIT
- 1Name of ) / (Address)
the_ _(24.4...et- _ ___tom _ - the body.
( ertaker or person ving charge rpse) (Inter,- o wise diep state horr -Datedi_7 1g f (Signed)._ I ) sawTbis Permi is sufficient for the Removal (and Interment or Cremation) of a body to an part 4
State (subject toe local cemetery or other regulations), unless removal is by common carrier.in which
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
MENTS OR CREMATIONS ARE MADE
Date of._.._._._.__ ___ �. xvieTZ
cremation)
(Signed)__...
(Person �/
in charge). sLtx e..[! . -!
(Name of Cemetery,C matorium,etc.) CJ
Person in charge must return this Permit to Regis of his District within
SEVEN(7)'DAYS from above date. If no person Ha 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 to its destination, where if
within te state of New York,it shall be delivered to the person in charge
of the place of burial.
§880. Duties of undertakers; interment within the state. If the inter-
meat 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.
§ 881. Interments. No person in charge of any premises on which
interments or cremations are made shall inter or t 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 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 deceased place of death, date of burial or disposal
and name and address of a un which record shall at all times be
open to official inspection; provi�t the undertaker or person having
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 hb�urriiaal,and shall write across the face of the permit the words "No
tperson he registrar of thud stinct file tin burial
hich the cemeteryvpermit ted. three days with
M!,SEXTONS and UNDERTAKERS violating the law relative to e
bun of is are liable to a penalty of NOT LESS THAN FIVE D
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.' Thelaw wilt lie enforced. Local Registrars,are required.under ,to repo