Sisson, Roy form os.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 6
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._
Village
Dist. No 32..G.County Qn.eidia or City Utica...S.tate...Hosp.i.tal
(If city, give street address)
Name of deceased Boy...Te.odore ►Sis.s.on... Veteran No
Single, married, widowed, (tf veteran, give name of War)
Sex Ma1.e..Color...White.or divorced (write the word) Single Date of Death July...16., 1961.
Age..6.5 Years 5 Months $.......Days Birthplace iOw.a.
Cause of Death Cerebral Hemorrhage
Certificate was signed by Dr......Ant.QA1. .QT.oCk.3.:W.... M.D.
Address...1213...C.our t...S treet.l. ...LU tic.a ...New...York
Place of Burial (or Removal) Glir?A$ raU s.y BeW...X.ork
(If body is to be temporarily held,811 In space later)
Cemetery ,Pine.,.Yiew...Cemetery Date of Burial July.. .18., 19...6i.1
(If body is to be temporarily held,SC, 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 Sullivan..&.Minahan..Inc.. G1ens...Fal1s.,...New...York
(Na
m.) !Address)
the Ud®ra ,e;' to hold temporarily and Inter the body.
(Undertaker or person having charge of corpse) (Inter, a ove,or th rwise dj�Dose of[state how])
Dated ITu�.y..,i.7,.} 19 61 (Signed) .... 4.,c.,. D t,, a.
pJ VIioeal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to✓✓ any part of the State (eabject to local
cemetery or other regulations), artless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of Z •ti/ wad_ 19 6 l
tia(Interment or _ ra)
1 y
:
(Ns of Cemetery, Creme. or Si, etc.)-.12
Section � , Lot No- /O Grave No.`
(Signed) y'� "� '��,
(P
Vim/!� .ry`�-
(Person in charge)
Address (�i 7- (
Person in charge must return this Permits
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is'in. charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.