Daha, Hector Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
. OFFICIAL BURIAL (OR REMOVAL) PERMIT
' This Permit eau 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No..26........._
Village
Dist. No 198 County..._..Alban. or City 113 Hol1,a d..Amerms,...A.1., 7aly.,...Diew..YLx.k
(If city, give street address)
Name of deceased Hector J. Daha Veteran li,'W I.
(If veteran. give name of War)
Single, married, widowed,
Sex Male Color White or divorced (write the word) Married Date of Death 12/4 19 61
Age 68 Years Months. ... ............ Days Birthplace Hudson Falls, New York
Cause of Death Bronchopneumona, bilateral
Certificate was signed by Louise P. Buckner M.D.
Address v A. Hospital, Albany? New York
Place of Burial (or Removal) Town of Queensbury, New York
(If body to to be temporarily held,fill in space later)
Cemetery S.t.....Aip.haxtsua Date of Burial 12/7 19.b.1..
(If body is to be 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 aag.au...and..zleauy...lu.0 .c.ai...Se.r.v.i,g a...i.ng..... ... 4.1...G.ga..SLK.eg.t.a...Ang...>;a.l.),. 4...Ngw..XAxk..
Under taker (Name) (Address)
the to hold tempor and Inn. X the body.
(Undertaker or person having charge of corpse) (Inter,remove,or t e anon of(state bowl)
Dated UJ.5 19 61 (Signed). .1.4.4..C...... [J
/ - al Registrar �! �/
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of thb Mate (subject to local
cemetery or other regulations),unless removal Is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSBIENT OF SEXIUN OR PERSON IN CHARGE OF
PRE4fI SES ON WHICH INTERMITS OR CREMATIONS
ARE MADE
Date of_kL t 4 >,-..:.,1 was '17 4_(. r 19(c
(Interment or Cremation)
J
(Name;'P Cemete1Vry, Crematorium, etc.)
6.
Section Ddv d l ' Lot No. 3 Grave No.
(Signed) 1�
( reon in charge)
f
Address .(3" ) (C O <J
,V
Person in charge mist return t is 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 OFii NSE.
The law will be enforced., Local Registrars are re—
quired, under penalty, to report violations thereof.