Brayton, Rebina Form yS.62.
NEW YORK STATE DEPARTMENT OF HEALTH , 7271
/
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed only by the Local Registrar (Deputy or subregistrer) 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
DURABLE LEGIBLY WRITTEN IN BLACK INK Town
—�-� /y V1'I a e // Reg><at red No.__.._......��
DEATH,
Dist. No.> Counnl /'��J-.....Y.�c.:. fr-4'�—/ or City .` ......,-- y, Ze,c..... 7.. :. --- 2(/
Y ����"C4 C � ;. /
/ (If city, give street address) /
Name of deceased / Z,,a t ..Z. </ Veteran
Single, married, widow d, / (11 ""' ' aiv nape of Wax)
�2. olor. 'JL�. g' �. / 19 .s
Sex�ktC G .or divorced (wnte the word'<. .... F , Date of Death ...
Age C O(5 Years Months Da s Bi plac _
Cause of Death...:.?:`..t.4�:,.. �... L t..c.: ,. 'zc�e .c5: c. r.?.'.k :F'4: cc - .( -4
G� 2�
Certificate was signed ....... :,,,v. / ... "�� 7.., , M.D.
Address ,..
Place of Burial (or emoval) / ..1.2.:Z"..C: .1,
(If body is to be�porartip h apace later)
Cemetery Ite:c f.:a .< ...:6:C.-e- .-- Z.�,l' .. et 1-, Date of Burial 19 `
(If body Is to be temporarily eld, 11 11n space Iater)
The Certificate of Death c taining 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 havecepted the same for registration, have recorded it in my Local Record with the above stated Registered
Nurejec
and op the ais t f I HEREBY GRANT A FERMI
to.. k ::Zr fiji.... 1. !,%l' .�'' -6:-.74"l —C..7(4 -;d .l'"�
me) � ressy
the . A x to hold tem orayii" and C d the body
( snake r person having charge co PO (lifter,rem th se disoose of[state how])
Dated.. . Z. .. / e) 19�,...� (Signed) ..C- ': ::I -' .. .-... I :/...6,.£ .,
L �ZEZI, .�Local Registries
This Permit is sufficient for the Removal (and Interment or Cremation) of a l dy to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case L Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
� l
Date .%Z/c -s-,...J wad J//u 19 ( 7
(Interment orctremedio
_7//A
(Name of Cemetery, Crematorium, etc.)
Section //"I' Lot No. S Grave No.7
(Signed)/`" -
(Person in charge)
Address G' -G/;' '1 —,�j„d„,/ 7, , ,
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the Isords
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.