Brayton, Robert Form VS 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No. 3 G e'( Q Registered No
Town /
County C jwv ..,Village. .. 7`�
or City (If city,give street address)
Name of deceased.....
Single,marri ,widowed,
Sex 11/1- Colo or divorced (write the word) ,YYl - Date of Death -1424g 6 19 3
Age y_ Years -
Months -•.Pays Birthplace.../ - `h ,,Y.
Cause of Death ,k-3- ,, - -
Certificate was signed by / � 1.1. , M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial ii- 7 19 3
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on the basis thereof I EREBY GRANT A PERMIT ,�,
to ;�„�Z�t.� "PA' .. ..,..... . %s�%i
Pam) (Address)
the Pi/i/f,f r to hold temporarily and agk the body.
(Under e r perrge of cause) ( ter m or oth rwise dispose of[state how]).
son having cha
Dated r 19—'9 (Signed) �r �
Local 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, in which case a Transit Permit (VS No. 62) is required.
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