Braydon, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dir 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 Li-6 O / Registered No °f oZ g
Town
County '` :•G� .... Village !� .. ,} 'c a,
—Wi.j,/
,qL �/J/ 4 (If city,`.give street address)
Name of deceased - /�....dl..li
/ 7/� Single, married, widowe , •
Sex.✓. 4 Color V .✓Le..or divorced (write the word) Date of Death ,/ 19 ?
Age £pp
.§ Yea S.S Months / Days Birthplace.�,l� /..�.f'
Cause of Death
Certificate was signed b __L� M.D.
g Y
Address %.,
Place of Burial (or Removal) ......... ,....... 1 / '
(If body is to be racily held, in space Ater ;27-e-- - /Cemetery .... /'= ✓ Date.of Burial /✓/ 193
(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 t basis the of I HE Y ANT A PERMIT
0 y, ,
e) ' :_dress)
the .. . to hold tempora it ......�.:��- ' .W the body.
(U aker person h v' g charge of ) `y *� or otherwise •ose of [state how])
e Dated �.. ifl 19 (SignedI ' 1ffI..d .. ...-... ....
Local begistrar
T rs Permit/sufficient for the Removal (and Interment or Crematio ) 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 requited.
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