Brayton, Margaret H NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name Middle Last Se
; ,.............. .................
Date of Death Age. H Veteran of U.S.4A &ii,
—/ �-�.
War or Dates
P..
Place of Death Hos ital, Institution or.--.
`.W City,Town or Village Street Address "
:::....:::::::::::
Cause of Death
s
Medical Certifier-- Nam � Ttle
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Addr ss
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G
G
Death Certificate riled l� District Nu be Register Number
City,Town or Village
Date C❑ t or Crematory Burial /! Q ry ry
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Cremation Addres -
Z' Date Place Removed
<Q ❑ Removal and/or Held
and/or Hold . ...................:...................................................,............,....................................,...........,..............................
Address ................................ ..........................................................................................................
a Date Point of
U) ❑Transportation by.. Shipment
pCommon Carrier «...,....................:..:...............:...........:........,..........,.,,......,.,...:............. .....:..,..,..,:.....,......:......,.............................................,....
Destination
❑ Disinterment
Date : Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to L Registration Number
Name of Funeral Firm
Address '� t
-
Name of Funeral Firm Making Disposition or to Whom /
Remains are Shipped, If Other than Above
Address
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Permission Is hereby granted to dispose of the hunpipf remains scri ed above as Indicated.
Date Issued �S — �) Registrar of Vital Statistics
A��'/'e
(signature)
a�District Number G,Place G�
I certify that the remains of the decedent identified above were disposed of in accorda ce with this permit on:
w! Date of Disposition /� 0207, Place of Disposition
(address)
!w
(section) (lot number) (grave number)
0' ' /
p: Name of Sexton or Person in Charge of Premises lelol'/ I Q 1)24
W: Signature (please print)Title
DOH- 1555(9/86)p 1 of 2(formerly VS-61)