San Souci, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. No. .1k601 County 5.03en0.Qt dV or City Schenectady
(If city, give street address)
Name of deceased .Mary Dela San.,Souci. Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex Females or divorced (write the word) Widowed Date of Death... December 3g— 1963
Age ee Years. +,. Months Days Birthplace.... - Iuclson FaI1S,2ti.Y.
Cause of Death Arteriosclerotic heart Disease- Genera ized Arteriosclero t
Certificate was signed by J. 'tacca M D
Address 862 - fian''ley Street
Place of Burial (or Removal) Glens Falls N.t.
(If body is to be temporarily held, fill in space later) �3
Cemetery St--A Date of Burial Dec 11 63
(If body is to be temporarily h Rat'tiF-kpace`1i�fb1') a
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 Edward-•--M•---P rsict Alisx-e•;Baxter ...&..•'Sort LPG-•Ne Bsw a Avenue.
(Name) (Address)
the.. Undo taker to hold temporarily and Inter the body
(Undertaker or person having charge of corpse) (Inter,remove or otherwise d'l�. e of [state how])
Dated.... ember 9— 19....63 (Signed)
Loc ' trar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo part of the S e (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ransit Perl it (VS s, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
`
Date of_ was " // 19 C�
p/ (Interment or Cremation)
eX�' l/ —e
(Name of Cemey, Crematorium, etc.)
LW'
_ Lot No. 7 Grave19
2)1
(Signed) _.. "
(Person in arge)
Address _
U , 7G ` 6 6
)1•
Person in charge must return this Permit o the Registrar
of his District within SEVEN (7) 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 Dis-
trict 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.