Harris, Pamela Form 9s.et. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr 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' E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No..-0 t
Dist. No.S67 County Warren ol� Queensbur 1 NY
(If city, give street address)
Name of deceased Pea J. Harris Veteran No
Single, married, widowed, (If veteran. give °""` of Wu)
Sex EMU—Color.V:rb?.#rf or divorced (write the word) Single Date of Death November 10 19..59.EMU—Color.
Age .6 Years....fl Months O..........Days BirthplaceGlen8..k:allat..NY
Cause of Death T 1 ... el tOgt..bux]a..maeaivve. VcteKkt
Certificate was signed by Se.ymaur...F....BQplaxt M.D.
Address Glens Falls,, NY
Place of Burial (or Removal).... .2. n...af..Queen.Sb.0 ,..NY
(If body is to be temporarily held,fill in space later)
Cemetery Scotch cemetery Date of Burial......Novel:41;er...13 19..59..
(If body is to be temporarily held,fill in space later)
Thin 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 Hudson Falls NY
to The Carleton Ftuzere�J. Home, Inc.
(Name) (Address)
the Undertaker to hold temporaril and Inter the body.
IIndertaker or person having charge of corpse) (Inter,remove,or oatse se of(scats howl)
Dated Novs 1,2 19..59... (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 use a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH 'INTERMENTS OR CREMATIONS
ARE MADE
C
Date of '?/1) 19 y 1
(Interment .
. ;Lc,
(Mane of Cemetery, Crematorium, etc.)
Section Lot No. Grave No,
{Si ed) L) C 2."2�
(Person in charge)
�
��Address fi ( {-yk-�
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 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 OFNNNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.