Braydon, H. Arthur Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir This Permit eau be signed only by t11111 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 CERTIELCATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registe No.._ ..".;:. .(:-
\-40
Dist. NotCounty. -WQ.-1 ",..., Village Atiet....v.....4 ,,
or City
(If city,give street aA Vd711;
Name of deceased /7/• eZ•11.4-1---1-t-4..--t__-•-t-- . ........ . . ,.
Veteran / a
h .1 Single, married, widowed, g 1 ' (If veteran, give name of War)/
Sex % Color v1/41 or divorced (wnte the word) 1A)A-14-7-61-4.1)Date of De,,,!e-41' 1,,,,.....")09 `-1 —
Age -...... ‘`.• Ye,,rts Mo ths , . .. Days , Birthplace. . ..-6,•?...%4 ,....v•
Cause of Death •
Certificate was signe b 4_.. f .1 - M D.
irn
Address .... •••••"
Place of Burial (or Removal) ...a3J) .,ete2 C.7) ---(ef
wer.'--A,_,_,___jor,/ r- /i.(If body la to porarily held,Oin space late
Cemetery... ....,e4.40...11..
qes4
--e Date of Burial
---17---'.--q / / 19
(If body body is to be emporarily held,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, AN SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local ..ccord with the above s Registered
Num and on .the basis.the HEREBY GRANT A PERMIT -...?----
IN Address)
the -1(-71/ to Vold temporarily and '^'? the body.
(tin rtaker or person hexing charge 9f corpse) u...-3,L(Inter,rem ye,or oth raise disnose of(state howl)
Dated .L. h.) 19. 4' ."--- (Signed)
' Local egistrs.r
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.
INDORSEMENT OF SEX'lUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
'----77 ---
Date o [--d z-,/ _ �'i'� / 19 6Zf
//l (Interment or''''. ,. (--77,/7 6/...„ '''''-----L
u$!!e
(Name of Cemetery, Crematorium, etc.)
Section / 91 Lot No. / 4 B Grave No.
(Signed) 27//'-'�LC%�i ..._ :-^ C �l l(5,
(Person 7n charge)
Address �l ' G �';fXjh/C� ..3'�� �C l di
/�/'/ `- •
c__...•+ - get-.-,:›Te".--‘47..) ''''%--7 ...y...,
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 words
"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.