Sansuci, Charles Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t2r 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 Nt1.54Town
Dist. No..5601....County Wa er Village Glens Falls Hospital
or City (If city,give street address)
Name of deceased Marisa'i@ a . :e... ansuei
Single, married, widowed,
SexMftlB Coior.f ,to...or divorced (write the word).....Widowed Date of DeathMay26 .m.49
Age 5a Years 5 Months 1.4 Days Birthplace Glens Falls x N. Y.
Cause of Death..Chroxri.tl...Cardl,Q..Vae.�r.T,tl:a" 41.494.119...A...E r'$rte of left foot.
Certificate was signed by Dr.... Harry....A9pan M.D.
,I,Adress Glans...Fa1.1.0.,...N.....:X.R
Place ,f Burial (or Removal) W.0 4.k...a ons Falls, N. Y!
(If bod^is to be temporarily held,fill in space later)
Cemetery St....ALPACIDAUA—COMMAAri Date of Burial May 29., 19 59
(If body is to be temporarily 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, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to aa...IA.... Q.t.ter Si]=.eI l... ' , 111.,..,. I,t..X...
(Name) (Address)
the U.nd er..talcer to hold tempor • ILter the body.
(Undertaker or person having charge of corpse) _. r,remove,o se dispose of[state how])
Dated May...2►.9.....19399 (Signed)
Local Registrar
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 regu.:-.dons),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
rill
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