Braydon, Mary l onn N R.6I. NEW YORK STATE..DEP-.AR'>~MENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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. Registered No.
T n.,.
Dist. No.. .b..i.County ge � -
.... . .. . ..
p� (� or City (If •city, •FiEt acldres.
N m of deceased �� , �., .. µ - -\ 5.1A1
Single, marri widowed, ` t 1Sex '� 'Color.. yr divorced ( the word) ' ... Date of Dea `�-- ,...k. 19..1,.E
Age �....‘.....,`,"ears ` ..Months _� Days Birthplac . ..
Cause of Death ci
X-C:A----kt °::, =�"e'v•t \,
Certificate was si ne by '~ .J `i;. ' a M.D.
` Addre -, r-. S�� a:1 ..
Place of Burial or Removal) Lr:.,/l.11. .'
((If body is to be mporariiy held, till Apace later) 4 r
Date of Burial '`�-- °... 19 Cemetery � �,�� , 's
—
ilt fir.. � �
ilf body- is to he temporarily held. till in apace later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to he 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 thersof LaR BI�'''lE2 �A PERMIT L_,
�, ..--— A .&1- \ . :.a c-k.
(Name) - (Address)
the to hold tempo 'ly and ... . .. the bod_y..,.
'n ertaker or person having charge of corpse) (Inter,remove,or erwise die; of[state ow])
Dated. t 19... ... t SiTrled)...:
'�-) Local It ar
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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