Brayton, Richard Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lz This Permit can be signed may by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death oecurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No._._. ._ ,..;L
// / Village //y
Dist. No...f. ..a4 County.. �fv.»� - Yc1.4..., or City 1 F C EA
/ (It city, give street address)
Name of deceased {� --(--P..�� r Veteran([i veers` - '
Single, married, widowed, - . give name of War)
Sex �Z.? Color er or divorced (write the wrd) t: - Date of Death ,,,�. �y 2-.�..19
Age..........17.• ..Yeas ,...Months Days , Birthplace 12.4.�;.:: Nc...
.
Cause of Death ... .rcuc...;;..:.:t , C ' ..... ...
Certificate was signed by : ..tea„ fit me-- M.D.
Address .......-..,f :e:4..1 . . J.
TPlace of Burial (or Removal) �Tlr/..?.; 2 .,. .s.i..t.-e�.c.,A... .. ..... � -�;
(If body Is to be ter rily held,fill typace later) / .
Cemetery �.e.�: -4' Date of Burial 4)/,-,1-- ;-1 k,. 19 5
(If body to to be temporarily fill in space later) /
The Certificate of Dea 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, and on the basis thereof.I HEREBY GRANT A PERMIT �� /
to i:.xz.L..a.�7 L:C:t:,7...4c : : ..�r .. y..A (r'
la - (Address) / the body.
the /!fit.-. to hold temporarily and.. h Y
(Underta or person having charge of corpse) . (Inter,respove,or otherwise Minos'of [state how])
Dated ...1..4.44.4... 19.5:.& (Signed) �' --- / .-:1
Local Registrar
This P 't 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. 82) is required.
.., C L14 sit ,:'
ENDORSEMENT OF SEXrUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
-- ' �i � --
Date of y' 1: t-r-� -¢ was - .4. ' .- l9
(Int or.- )::Las)
as i
a
(
C� ri
c ' ' -,(-1d.. - /'
(Nine o Cemetery, Crematorium, etc.)
Section P Lot No. i Grave No.
r
(Signed
// �;/ -�41 I
77;.---"� Cs';1'C�..�!� ', r�—sd-
L
(Person in charge)
Address C C C.�-i'Y 1) f.:62._ ,-5�-+�-�-- - / /-
/x -Y:f2e., ,- a-_-_,,ef:-., '-';---22 , .› ,
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 w rds
"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.