Braydon, Ann NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ACWWThis Permit can be signed only by the Local Reg istrar(Deputy or Su istrar)of the Primary Registra.
tion District(Town,Village,or City)in which the death occurred after the FILING and nce of a COR-
RECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLECK INK.
Dist No....5.6.0.1.. Registered No.------....—...
...._......._..
_rre�...._ 11.... _ 4 _I /
-- ate of Death_
Ta -o Glans Falls, NiY. g-
loge,or City'-.-------W----•- +----... .�.-_ ! Sea. Age..f� Yrs. Color..
(If city,give street address) (Or Mos.)
Cause of Death._........ . . _..__.
Place of B (yr Removal)42 t l./...-t t/
Cemetery. ' _._ ... --- Date of Burial ...i9
Certificate of Death of.._.._. ---.-_
(Give full name of d}
having been presented to me containing the above stat particulars and, after careful PTAminttion
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
N
the a e stated Registered ,an on the basis th I/EREBY A P
174,
•
(N of on
th or
re or person wing charge of corpse} (In
Dated _ 19...e / (Signed).- -�-. i'3 , '- .
This Permit is sufficient for the Removal(and Interment or Cremation)of a body to any •
Tree(subject Permit to CO ieO";,r�.i aother` aUaae), less removal is by common carrier,In w:f'
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