Harris, Paula Form vs.a. 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 CERTTMTE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.21. .............
LYZUPX
Dist No 5657 Cott Warren &mg Queensburxl NY
(If city,give street address)
Name of deceased P?.A1A L. Baja Veteran N4
Single, married, widowed, (If veteran, give name of War)
Sex Fern Color 1 hiteor divorced (wnte the word) Single Date of Death November 10 19 59
Age 0 Years 6 Months 1 Days Birthplace k'h1.1. ,..H
Cause of Death Third degree burns massive extent
Certificate was signed by Seywl.93lr F, Hopfan M.D.
Address. O1 ii. F, ,ls,,,,NZ
Place of Burial (or Removal) TQ XI of QtlQ,vnsbury, NT
(If body is to be temporarily held,fill in space later)
Cemetery Scotch Cemetery Date of Burial November 13 19...59.
(If body is to be temporarily held,rill in space Iater)
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 Carleton Funeral Home, Inc Hudson Falls, NY
(Name) (Address)
the Un.dertak r to hold temporaril and IXl X' the body.
(Undertaker or person having charge�r corpse) (Inter,remove,ear of ■nose of s is how])
Dated Nova 12 19...72. (Signed) e�ti�: ....r... :� -c':.,i.
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 SIMON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERIMS OR CREMATIONS
ARE MADE r
, r
Date of i was , . 19c37
(Interment or )
fa ( ;(Ne oftery, Crematorium, etc.)
Section '""��. Lot No. Grave No.
.
(Signed) 7,..---":';‘, �`„ Ce
:--):2/.(:
17
(Person in charge)
r
Address C P �-1 ,,,,‘‘
Person in charge mast return this Permit to
the Registrar of his District within SEVEN (7) ,DAYS
frown 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.