Rawson, Martha 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. Registered No.__.2114
5601 Warren ,d 4 �f e
Dist. No. County or City 01.-en-a..Falls
(If city, give street address)
Name of deceased Martha Rawson Veteran
- (If veteran, give name of War)
Female •
Single, married, widowed, Widowed 12 6
Sex or divorced (write the word) Date of Death -5� 1f 19
Age $1 Years Months Days Birthplace
Cause of-Death Acute yocardial Infarction
Certificate was signed by Har.o1d...J.... .Luria M.D.
Address 25 May Street
Place of Burial (or Removal) c We.�f:�t..,.Ctlen5...Falls,... .LX.�t
(If bodye is to be tetgpprCstheuiengr ails 5114 64
Cemetery -west (i1 Date of Burial 19
(If body is to he 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 James S. Potter Glens. ? fl
(Name) (Address)
the Undertaker to hold temporarily and Inter the body
(t> a .to,aker person having charge of cotzsp) (Inter,re or otherwise di pose of [state how])
Dated ) 1/'+, 19 (F, (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 regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 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 /,f w19_
(Interment or Cremation
/ :
(Name of Cemetery,Crematorium, etc.)
Section - ' Lot No. Grave No.
Si ned 6��� 1L'�G+� "1 ef-40-7- 116
(Person in —harge)
Z.Address � L� -_� %-+�2�'
Person in charge must return this Permit to 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.