NEW YORK STATE BOARD OF HEALTH—BUREAU OF VITAL STATISTICS 
RECORD OF DEATHS 
CHAPTER 661 OF LAWS OF 1893. 
SECTION 23. ****** * Every undertaker, sexton or other person having charge of any corpse, shall procure a certificate of the death 
and the probable cause duly certified by the physician in attendance upon the deceased during his last illness, or by the coroner where an inquisition is 
required by law, and if no physician was in attendance, and no inquest has been held or required by law, an affidavit stating the circumstances, time and 
cause of death, and sworn to by some credible person known to the officer granting the permit, and there shall be no burial or removal of a corpse until 
such certificate or affidavit has been presented to the local board or to the person designated by it, and thereupon a permit for such burial or removal has 
been obtained. ******* 
SECTION 22. * * * * * * * The person making such certificate shall be entitled to the sum of twenty-five cents therefor, which shall be 
a charge upon, and paid by the municipality where such * * * death * * occurred. 
The undertaker should secure the complete filling out of the last portion of this certificate by the head of the family, or other responsible friend, and 
should then obtain the medical certificate from the attending physician. 
No permit shall be issued by the local board of health or its representatives for the burial or removal of a corpse until the certificate or affidavit has 
been presented and is properly and correctly filled out. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village or city where it occurs. 
NOTE.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of Health, as provided by the law for the Registry of Marriages, 
Births and Deaths. 
|J3|PThis Certificate, when filled out, is to be registered without delay, and forwarded to the State Bureau of Vital Statistics, Albany, on or before the 5th of the 
next month. 
Ink must be used in filling out certificates. Use great care in writing proper names, dates and places. 
CHAPTER 138 OF LAWS OF 1897. State of New York—Bureau of Vital Statistics 
County <| 
Town of 
Village 
City of.. 
Full M 
(If an infai 
f State 
, ( 
ame of Deceased, 
it not named give family name.) 
of New York—Bureau of Vital Statistics 
Certificate and Record of Death Re,Ei!,tere<1 
I hereby 
that I last 
on the 
ertify that I attended deceased from igo to /go 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
• 
Contributing cause, 
Sanitary 0 
Place of Bu 
Date of Bur 
Undertaker. 
Witness my hand 
'ial, 
lal. 
this.. day of /go 
M. D. 
(Signature), 
Residence, 
Reside 
ire ...... 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Age, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.^ 
Birthplace. 
Mother’s 
Name. 
How long in 
U. S. if foreign 
born, j 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFI CATE WILL B E R EC EIVED 
Years. Months. 
Days. 
1 
Single, Married, Widowed or Divorced, • 
or Coui 
I Years. Months. 
Days. 
How long In | Years. Mouths. | Days. | 
How lone: a Resident here, 1 
States If 
/oreiern born' 
Date of Death, 
Reported by 
Chief Cause of Death,— — 
Certified by , M. D. 
Medical Attendant. 
Buried at - - 
By , Undertaker. 
Residence, 
This stub will not be received as a certificate of death. Chapter 66 i of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per* 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
This Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month. State of New York—Bureau of Vital Statistics ; 
County of STATF 
Town of 
Village of 
Citv of 
of New York—Bureau of Vital Statistics 
Certificate and Record of Death Ree“No- 
Full Name of Decea 
(If an infant not named give family 
sed. 
name.) 
I hereby 
that I last 
on the 
ertify that Iattended deceasedfrotn /go to /go. . 
aw alive on the dnv nf r™ thnt //w 
/. or P. M., and 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
bservations. 
Witness ?nv hand this ..._dav nf„ . ,nn 
M. D. 
Place of Burial, 
Date of Burial, 
Undertaker. 
(Signature), 
Residence, 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Age, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.*] 
Birthplace. 
Mother's 
Name. 
How long in 
U. S. if foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
| Years. | Months. 
Days. 
Single, Married, Widowed or Divorced, 
Occupation, 
Father’s Name, 
Father’s Birthplace 
Mother’s Name, — 
Mother’s Birthplace, —. 
Place of Death 
Years. Months. 
Days. | How long In | Years. Months. | Days. | 
How long a Resident here, 
States if | | J 
iforeiern born ' 
Date of Death, 
Reported by. 
Chief Cause of Death, 
Certified by , M. D. 
Medical Attendant. 
Buried at 
Residence, 
I3P“ This stub will not be received as a certificate of death. Chapter 661 of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
HdF" This Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month. State of New York—Bureau of Vital Statistics ; 
County of STATF 
Town of 
Village of 
City of 
Full Name of Deceased, 
(If an infant not named give family name.) 
of New York—Bureau of Vital Statistics 
Certificate and Record of Death Rei['stered No- 
I hereby c 
that I last 
on the 
ertify that I attended deceasedfrom igo to igo.. . 
aw aline nn the gay of rgo that died 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
bservations. 
Witness mv hand this dav of mn 
M. D. 
Place of Burial, 
Date of Burial, 
Undertaker. 
(Signature), 
Residence. 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Ape, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.^ 
Birthplace. 
Mother's 
Name. 
How long in 
U. S. if foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
Full Name of Deceased,— 
— 
| Years. 
Months. 
Days. 
Single, Married, Widowed or Divorced, 
Father’s Name, 
Mother’s Name, 
Mother’s Birthplace, 
Place of Death, 
How long a Resident here, 
Date of Death, 
Reported by 
Date, 
Chief Cause of Death, 
Certified by 
Buried at 
By 
Residence, 
— 
Years. 
Months. 
Days. | How Ion 
g in 
ted 
if 
orn. 
Y ears. 
Months. 
Days. 
States 
.iforeitrit 1 
, M. D. 
Medical Attendant. 
This stub will not be received as a certificate of death. Chapter 66 i of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
C®“This Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month. County of STATE 
Town of 
"Village of 
City of 
Full Name of Deceased, 
(If an infant not named give family name.) 
of New York—Bureau of Vital Statistics 
Certificate and Record of Death Reeis,ered No- 
I hereby 
that I last 
on the 
ertify that I attended deceasedfrom zgo to igo... . 
aw. -..-.alive on the day of zgo that died 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
bservations. 
Witness mv hand this dav of mn 
M. D. 
Place of Burial, 
Date of Burial, 
Undertaker. 
(Signature), 
Residence. 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Age, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.^ 
Birthplace. 
Mother's 
Name. 
How long in 
U. S. if foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
State of New York—Bureau of Vital Statistics ; 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
Full Name of Deceased, i 
Years. | Months. 
Days. \ 
Single, Married, Widowed or Divorced, — • 
Occupation, J 
Father’s Name, - J 
Mother’s Name, - J 
Mother’s Birthplace, « 
Place of Death, - I 
lYears. Months. 
Days. | How long in [Years. Months. | Days. | \ 
How long a Resident here, 1 
States if j | ! a 
.... dforeicra born ' ■ 
Date of Death, • 
Reported by ... ! 
Chief Cause of Death, ■ 
Certified by , M. D. ■ 
Medical Attendant. , 
Buried at- ! 
Residence, • 
This stub will not be received as a certificate of death. Chapter 66 i of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
HP This Certificate, when filled out, is to be registered without delay, and forwarded to the .State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month. State of New York—Bureau of Vital Statistics ■ 
county of State of New York—Bureau of Vital Statistics 
VillMreof Certificate and Record of Death N»- 
Full Name of Deceased, 
(If an Infant not named give family name.) 
/ hereby 
that I last 
on the 
ertify that I attended deceasedfrotn iqo to igo.. . 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
Place of Bu 
Date of Bur 
Undertaker 
Residence,- 
bservations. 
Wit 
rial, 
ial, 
ness my hand this... -day of. /go 
M. D. 
(Signature), 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
.... - - 
Age, in years, 
1110s. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
word> not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.^ 
Birthplace. 
Mother's 
Name. 
How long in 
U. S. if foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
Full Name of Deceased, 
Years. 
Months. 
Days. 
Single, Married, Widowed or Divorced, 
Father’s Name, 
Mother’s Name, - 
Mother’s Birthplace, 
Place of Death, 
How long a Resident here, 
Years. Months. 
Days. | How long in [Years. Months. | Days. | 
States if 1 | ! 
lforeiara born. 
Date of Death, 
Reported by 
Date, 
Chief Cause of Death, 
Certified by 
Buried at 
By 
Residence, 
, M.D. 
Medical Attendant. 
This stub will not be received as a certificate of death. Chapter 66 i of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month, State of New York—Bureau of Vital Statistics 
County of STATE 
Town of | 
Village of 
City of 
Full Name of Deceased, 
(If an infant not named give family name.) 
of New York—Bureau of Vital Statistics 
Certificate and Record of Death Resl9,ered No- 
I hereby 
that I last 
on the. 
ertify that I attended deceased from /go to /go— 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
lA/itness mv hand thi.t Aav of rnn 
M. D. 
Place of Burial, 
Date of Burial, 
Undertaker.. 
(Signature), 
Residence. 
Residence . 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Age, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country:-] 
Birthplace. 
Mother’s 
Name. 
How long in 
U. S. i f foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
Full Name of 
Deceased,— 
— 
— 
— 
Years. 
Months. 
Days. 
Single, Married, Widowed or Divorced, 
or Corn 
Father’s Nam 
Father’s Birtl 
Mother’s Nar 
Mother’s Bir1 
Place of Deat 
How long a F 
Date of Deat 
Reported by. 
Date, 
Chief Cause o 
ne, 
.esident here, 
h, 
How Ion 
the Un 
States 
foreign 
Years. 
Months. 
Days. 
gin 
ted 
if 
)<>rn 
Y ears. 
Months. 
Days. 
. 
Certified by... 
Medical Attendant. 
M. D 
By 
Residence, 
, Undertaker. 
This stub will not be received as a certificate of death. Chapter 66 i of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
tgpThis Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month. State of New York—Bureau of Vital Statistics 
County of 
Town of 
Village of 
City of 
Full Name of Decea 
(If an infant not named give family 
State 
i 
sed. 
of New York—Bureau of Vital Statistics 
Certificate and Record of Death Reeis,ered No- 
name.) 
I hereby certify that I attended deceased from /go to igo 
that I last saw alive on the day of igo. , that died 
that to best of my knowledge and belief, the cause of. death was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
Witness mv hand this dav nf rnn 
M. D. 
Place of Burial, 
Date of Burial, 
Undertaker 
(Signature), 
Residence. 
Residence,- 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Age, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an Insti- 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.*] 
Birthplace. 
Mother’s 
Name. 
How long in 
U. S. if foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
Full Name of Deceased,— 
I Years. 
Months. 
Days. 
n6c 
Single, Married, Widowed or Divorced,- 
(Stat 
or Coui 
Mother’s Name, 
How long a Resident here 
Date of Death, 
Reported by 
Date, 
How Ion 
Years. 
Months. 
Days. 
gin 
Years. 
Months. 
Days. 
States if 
foreign born. 
Certified by 
Medical Attendant. 
M. D 
By 
Residence, 
— 
, 
Undertaker 
This stub will not be received as a certificate of death. Chapter 661 of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
IjrWThis Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month. State of New York—Bureau of Vital Statistics ; 
County of 
Town of 
Village of 
City of 
Full Name of Decea 
(If an infant not named give family 
State of New York—Bureau of Vital Statistics 
Certificate and Record of Death Re,£,!“ered No- 
sed, 
name.) 
/ hereby 
that I last 
on the 
ertify that I attended deceasedfrom 190 to 190— 
that to best of my knowledge and belief, the cause of. uleath was as hereunder written. 
Duration of Disease 
Chief Cause, 
Contributing cause, 
Sanitary 0 
Witness mv hand this dav of...... mo 
M. D. 
Place of Burial, 
Date of Burial, 
Undertaker, 
(Signature), 
Residence, 
Date of Death. 
Year. 
Month. 
Day. 
Place of Death. 
Age, in years, 
mos. and days. 
How long 
Resident here. 
Sex. 
If in an 
tution give 
name and 
location. 
Color. 
[Strike out 
words not 
applicable.] 
White. 
Black, [Negro or mixed.] 
Indian. 
Japanese. 
Chinese. 
How long an 
Inmate. 
Previous 
Residence. 
Single, Married, 
Widowed or 
Divorced. 
Father’s 
Name. 
Occupation. 
Father’s 
Birthplace. 
[State or Country.'] 
Birthplace. 
Mother’s 
Name. 
How long in 
U. S. if foreign 
born. 
Mother’s 
Birthplace. 
[State or Country.] 
REPORT OF DEATH 
FILL OUT WITH INK AND WRITE PLAINLY 
MARGIN RESERVED FOR BINDING 
NO MUTILATED CERTIFICATE WILL BE RECEIVED 
Full Name of Deceased, 
| Years. | Months. 
Days. 
1 1 
Single, Married, Widowed or Divorced, 
Mother’s Name, 
Place of Death, 
1 Years. | Months. 
Days. | How long in (Years. | Months. | Days. | 
How loner a Resident here, 1 
1 States if 
Date of Death, 
Reported by - 
Chief Cause of Death,— - 
Certified by , M. D. 
Medical Attendant. 
Buried at - 
By _, Undertaker. 
Residence, - 
This stub will not be received as a certificate of death. Chapter 661 of Laws of 1893. 
Section 23. ******* Every undertaker, sexton or other person having 
charge of any corpse, shall procure a certificate of the death and the probable cause duly 
certified by the physician in attendance upon the deceased during his last illness, or by the 
coroner where an inquisition is required by law, and if no physician was in attendance, and 
no inquest has been held or required by law, an affidavit stating the circumstances, time 
and cause of death, and sworn to by some credible person known to the officer granting the 
permit, and there shall be no burial or removal of a corpse until such certificate or affidavit 
has been presented to the local board or to the person designated by it, and thereupon a 
permit for such burial or removal has been obtained. When application is made for a per- 
mit to transport a corpse over any railroad or upon any passenger steamboat within the 
state, the board of health, or the officers to whom such application is made, shall require 
such corpse to be enclosed in a hermetically sealed casket of metal or other indestructible 
material, if the cause of death shall have been from a contagious or infectious disease. 
CHAPTER 138 OF LAWS OF 1897. 
Section 22. ****** The person making such certificate shall be entitled 
to the sum of twenty-five cents therefor, which shall be a charge upon, and paid by the 
municipality where such * * * death * * occurred. 
The Law requires that the Certificate of a Death shall be returned and registered in the town, village 
or city where it occurs. 
Note.—Certificates of Death and all Blanks are to be procured of City, Village and Town Boards of 
Health, as provided by the law for the Registry of Marriages, Births and Deaths. 
Certificate, when filled out, is to be registered without delay, and forwarded to the State 
Bureau of Vital Statistics, Albany, on or before the 5th of the next month.