Harris, Jack Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 CERTIF AAE OF
DEATH, LEGIBLY WRI ITEN IN DURABLE BLACK INK. Town Registered No—. �4,,i1.._._...__
Malign
Dist. No 5657 County Warren Queensbury,, NY
(If city,give street address)
Name of deceased J.ack..fl... Harrio Veteran No
Single, married, widowed, (if veteran, give name of War)
Sex Male Color l+hite or divorced (wnt the word) Single Date of DeathNovell>ber 70 19 59
Age 4 Years 1 Months Days Birthplace Glens Falls, NY
Cause of Death Tb.ird..degree...burns.Jt1asei.Y.e..ext.extt
Certificate was signed by aeymAux..1....Hcp .an M.D.
Address g L m Fall§., NX
Place of Burial (or Removal) ` .OItT)...af...gmee.Il bl•3 'y
(If body is to be temporarily held,fill in space later)
Cemetery SCRtC.h Centeter.y Date of Burial November 13 19.59..
(If body is to be temporarily held,Jill 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 The...Car1et.on.. :uuer.al .Home.t...Inc. F,ide= Fall.§.,...N1
Undertaker (Name) (Address)
theto hold tempos rily and Inter the body.
(Undertaker or person having charge oc corpse) (Inter,remove,(4"F)itt te�*6disnose of[state how])
Dated 4ORa 1.? 19.....9 (Signed) .--1'�e 7 ; •�:..ka-.t....•
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.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of -c.4 was.i f 7 19C /
(Interment or Cr t on)
(Name of Cemetery, Crematorium, etc.)
Section ,__""" Lot No. Grave No.
4%17
(Signed � �j � .. '• C/-
(Person in Chit
Address •
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"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.