Branson, Harold NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DU BLACK INK.
Town,
Registered No.- 4
Dist. No z. � County Dt41.chrir$$ ;,
t (If cit , give street address)(
Name of deceased 1y'.�,�. ,ice- � Veteran
(If veteran, give name of War)
Single, married, . .. -.► —=-
Sex.._....... . or divorced (wri .rd). :Cdr.,/Date of Deat ..,, 19�n,C
Age �.,c2 �YFear Months D. Birthplace /.,:�' ,,:._
Cause of-Deatht:,. e 1. ..z ..• I.... , : : ..�:--., ,..y`ryz
Certificate was signed by � % -; ' -C-C.. ,z..., ' M.D.
Address 1:1.ck- .4 . .£ ,4 : ... AC' > - .
Place of Bur' (or Removal).. .�-txv - ��, .. . -:Que y...i!daKxe ...0.s...NAY:
(If body is to b orarily held, fill in space later)
Cemetery..... -- 44.14o f Burl. .... '' /i 19 f
(If body is to he temporarily held, fill in space later) s
The Certificate of Death containing the above stated particulars, havin•'l.ee presente .o me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SA . FACTORY A •EQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Loca •'ecord withros. . .ove stated Registered
N er, n on 22sisth... HEREBY GRANT A PERMIT A i
(Name) (Address)
the to hold temporarily an . ' , / the body
(Un rtaker or rson having charge of c se) , (Infer,re ve, or otberwi dispose of [state •w])
Dated ef 19''S- (Signed) a....C:-- .7-'; ..e 1—/e.Z4.«'
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation 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.
Form VS. 61. (Rev, 6/63) (3A2-333)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of was �j19.
(Interment or Crematio
Branson—Seelye Cemetery
Dunhams Bay, La.tse George, NY
(Name of Cemetery, Crematorium, etc.)
Section Trot No. Grave No.
(Signed) h
68 Main(Psrtoreetarge)
Hudson Falls, NY
Address
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict 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 required, under penalty,
to report violations thereof.