Braydon, Addie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far' 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. .
-- ,e7-
Town, Village
Dist. No. ...k,-1-Fc" e---' / Coun y . .'./. ------ or City ' -P.-..,,r4...kcm
(If city, give street address)
Name of deceased
-(..,,e,...ee...../..... . Ar---..c...-- Veteran
(If veteran, give name of War)
Single, married, widowe ,
Sex 7...0----,--- or divorced (write the word) nte of Death i'--- .--5 19
Age --77 Years Months Days ...,...i., _..... Birthplace
Cause of Death —?.. '---Certificate was was signed by , M.D.
Address
Place of Burial (or Removal) --,
--e.r.....z.e_.3.4.....,_.....‹..r...,-e...<0,-
(If body is to he temporarily he in in spacel=r51—_,
Cemetery fate of Burial 19
(If body is to he temporarily held, ill space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
6d-pel.-
172..the (ACICI.i.ess).... to hold temporarily and ci(Z.ez:. the body
(Unde ta r or person having charge o copsg) (Inter remove, or otherwise dispose of (state how))
Dated , 19 (Signed)
/ al2g
Thi ermit is sufficient for the Removal (and Interment or Cremation)of a body to any part o he State (s ject 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) (3A2-323)
•
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
y..— was
r /
Date of ` �:INi 19 /'
(Interment orb )
•
(Name of Cemetery, _ c.)
c..
l - v41& '
Section /1 Lot No.__ Grave No. c7:: ',
7.
(Signed ,'
`/ )-4"(Person in Charge)
Address /!/
il-1- i V W f / /
e]Person in charge must return this Permit to theegistrar
of his District within SEVEN (i) 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 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 required, under
penalty, to report violations thereof.