Mason, Olive NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gFrThia Permit can be signed only by the Local Registrar(Deputy or Subregiatrar)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 CRTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK /
Dist No..-__(-(�_-s5- -s._ Registered o. � `T`
County_ ._ _ _ Date of Death_.. _ 9
T�wa„Vil-
Jirtge-itSex_ Age %✓ Yrs. Colorlage,
(If city,give street address (OrMosJ
Cause of Death_.._. -- - __ _.__ . -
Place of Burial(or val)_----•- ___-_ -Nru�_.._---. _-- _.--------.._
Cemetery ...-. ............._____....._ Date of Burial
Certificate of Death of
(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 s e for registration,have recorded it in my Local Record with
the above sta d Registered ber, don the basis f I HER 5t NT A PERMIT
to 7
of de (Address)
the. to the body.
(U er r rson had harge o �s�y (In remove,or othe ise ose of[ to ow])
Dated 19 y (Signed)_
Lo 1 egistrar
T is Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of he
State (subject to local cemetery or other regulations), unless removal is by common carrier, in which case a
Transit Permit(VS No.621 is required_
INDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTER-
ME S OR CREMATIONS ARE MADE
)ate of....�
( rm or cremation)
Signed) . . �....�......_.._._
Person r
n charg a)
.—. .. me.
- Name of Ce tkry,Cremator- ium,
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
he 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
laving charge of the corpse,shall file the certificate of death with the registrar
if the district in which the death occurred and obtain a burial or removal
prmit prior to any disposition of the body. * • * The undertaker shall
leliver the burial permit to the person in charge of the place of burial, before
nterring or otherwise disposing of the body; or shall attach the removal
)ermit to the box containing the corpse,when shipped by any transportation
:ompany; said permit to accompany the corpse to its destination, where if
vithin the state of New York,it shall be delivered to the person in charge
if the place of burial.
§ 880. Duties of undertakers; interment within the state. If the inter
nent,or other disposition of the ody is to be made within the state,the word-
ng of the burial or removal permit may be limited to a statement by the
•egistrar,and over his signature,that a satisfactory certificate of death,having
een filed with him,as required by law,permission is granted to inter,remove
)r dispose otherwise of the body,stating the name, age,sex,cause of death,
Ind other necessary details upon the form prescribed by the commissioner of
iealth.
§ 381. Interments. No person in charge of any premises on which
nterments or cremations are made shall inter or permit the interment or other
lisposition of any body unless it is accompanied by a burial, cremation or
•ransit 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
late of interment or cremation. He shall keep a record of all bodies interred
r 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.
Ind name and address of the undertaker; which record shall at all times be
yen to official inspection; provided that the undertaker or person having
:harge 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 burial,and shall write across the face of the permit the words "No
person in charge,"and file the burial or removal permit within three days with
the registrar of the district in which the cemetery is located.
IOW"SEXTONS and UNDERTAKERS violating the law relative to the re-
turn of permits are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
few will be enforced. Local Registrars,are required,under penalty,to report
violations thereof.