Harris, Penny Perm VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District yawn,
Village, or City) in wrhich the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI AOF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town
X Registered No._....._..�:._
Dist. No 5b57 County Marren 4X� Queensbury 2 NY
(If city, give street address)
Name of deceased Penny J, Harris Veteran No
(If veteran, give name of War)
Single, married, widowed,
Sex Felpal.e ColortThite or divorced (write the word) Single Date of Death November 10 19,,.59
Age 3 Years 1 Months 3.5......,....Days Birthplace Olen F847.l.a.,..NI
Cause of Death Third degree burns massive extent
Certificate was signed by Seymolax..E....Ropfan M.D.
Address. Olemiz F411.4,. .NT
Place of Burial (or Removal) TQWX1..0.r QUPIII.4bAr.y..,...1T
(If body Is to be temporarily lipid,till in space later)
Cemetery Scotch Cemetery Date of Burial November 13 1959...
(If body is to be temporarily held,All 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...C.axle.ton..ktaneral...Hottte,...In ............. Fi.ldgaa...F.a l.s,..NY
(Name) (Address)
the Undertaker to hold temporaril and Inter the body.
(Undertaker or tenon having charge corpse) T (Inter,remove erwise snose of(state how])
NQ Dated Y le 19.....59 (Signed) It." ..�.2 : .a.-r:`C
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (enbject 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE `]�
Cea1 c -
—74
Date o /72,fl f t4/2in7T `..3 19 °J
(Interment or
(Name of Cemetery, Crematorium, etc.)
Section — Lot No. Grave No
(Signed) >4?j' _.- . -�—.
( peon in charge)
Address W7.----721/"._z
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 DLRECTORS 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.