Brayton, Fred Form vs. ai.. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tom' 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. Re t ed No.., .3
y Towng ,? t�!(�� ll6„�/
Dist. No, lo.a./.Count• �(9'1,7 1.2_ Village
ity (If city,give st t address)
Name of deceasedcZ: ���C � .
Single, married, widowe
Sex � Color. ' or divorced (wri e t/h�..word)L .......Date o Death:.. . .. .::. . .. .... ... .19. 1
Age... rs Yea M � `T D •s __ Birthplace. ,-,:'
Cause of Death.... ..
Certificate was signed by .... .=.•..1T1 M.D.
Address ys��.. .„---et--sc r�.�.f �� <,--
Place of Burial Re val) ,...� � f l,,t-, -- ��
‘, .
(If body is t to oraril eld fill ins ater)
Cemete Date of Burial .�lh�t C..l� 19
(If body is to be tempor held, fill in space later)
The Certificate of eath con'• ;ning the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing t(. he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have acc ed the same for registration, have recorded it in my Local Record with the abov stated Registered
Num er don the �EREBY GRANT A PERMIT
to 5 , G ...
e / ddress)
the to hold temporarily the body.
y.
(Und _ r or person having charge of corpse) (Inter, othWe dispose of[state how])
Dated, . - L....../ 19.% ' (Signed).., .. �...... /�
Local Regis ar
This 1'-ermit 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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