Brayton, Walter Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signet; 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. Registered No.
�� Town / ,/
Dist. Ncty '..l County. . %l!/.. Village....c;Ze, .2! L
or City (If city, give address)
Name of deceased AL��� .... ,..( . City,.___
�/ Single, married, widowed,
Sex Color �v or divorced (write the word)..:--. .Gt..;1 -el Date of Death, /.2',-‘--e - 19`f..?
Age 6 7 Years `J Months....a.�,t`' Days Birthplace..�`f-�Gc:47a..1 .a. `f..i.........
Cause of Death .� pp.
Certificate was signed by :✓. -J.4:tn f M.D.
Address /... .�........ ..-exrt-k.....
Place of Burial (or Removal) s 7`
(If body is to be to oraril held,fill in space later)
Cemetery Date of Burial. • //l 19/-G-_
(If body is to be temporarily h , fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, 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, don the basist4eeeof j El'o Y GRANT A PERMIT "
to
! (f (Address)
the .arc. ( ame)/a .4-c_. to hold temporarily and ,..c.ra. the body.
(Undertaker operson having charge of corpse) t �n�r,�J'e v or otherwi nose of [eta bow])
rated 19 (Signed) YL�•••M-
Local Regis
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o he 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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