Brayton, Leander 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.
Town, Village
Regist N `, 7�
Regi=
Dist. No........5CC)/ 'aunty -'2 6Z A-- or City
�J (If city, give street address,_
Name of deceased t/ ?C� Veteran (eZ2 .,.,_.,
(If vet ran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) 4Date of Death .. 7/ 19 4"
Age.....3'./ •
Years Months Day Birthplace
Cause of Death d d--C,-�,�1.0 � ~
//x-
Certificate was signed by /1 // ,.
rg M.D.
Address .<) C.
Place of Burial Removal c
(If body is to be porarily },� d, i iry ace ater
411' ,/ ,/
Cemetery ,L� , r�.,L.Q_4(.1a..`c(e. .. z Date of Burial 19,.,7
(If body is to b temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above aced particulars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accept d the same for registra-
tion, haver orded it in my L cal Record wi the above state Registered Number, and on tlbasis the of I HEREBY GRANT A
PERMIT n 1
/l
�/;t
Na e) ,/ (Add ss� /
the "'` .... .. ,, <� to hold temporarily and the body
(Undertaker erso axing charge of S.grrpse) nter, remove, or otherwise dispose of (state how))
Dated 19 (Signed)
•
This Permit is sufficient for the Removal (and Interment or Cremation)of a bo to an .part`oTTh, ktrar(subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit ermit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
45y 11,
Date of was ( "1 �i 19 7
(Interment or Crewe oii)"
(Name of Cemetery, c_ ,,,,t; __r-e
Section �j Lot No. Grave No.
C--- osZr---e-r-
(Signed 44, O
(Person in Charge)
Address 'G '';117 ' jef''
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. If tip
person is in charge, the FUNERAL DIRECTOR or UNDER
TAKER MUST SIGN ABOVE STATEMENT,write across'
face of the Permit the words "Nod person in charge," and-
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
A
of District in which cemetery is located. ,,�``
1,
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.