Haas, James NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. p
g , Village Registered No. IV
V
Dist. No. 5724 County Wadi ngton of& {} Ft....Edward, NY
(If city, give street address)
Name of deceased James A.t Haas Veteran No
(I( veteran, give name of War)
Single, married, widowed, Married
Sex Male or divorced (write the word) Date of Death October 8 19 66
Age 63 Years. Months Days Birthplace Town of Easton, NY
Cause of-Death Coronary Occlusion
Certificate was signed by M.J_Gx Qenbx9., M.D.
Address I',_us slar7.,.E,al, , .,, NY
Place of Burial (or Removal) Town of Queensbury
(If body is to be temporarily held,_ell in space later)
Cemetery mne view Cemetery Date of Burial October 10 19 66
Of body is to tie temporarily held, 1111 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 SATISFAC;1 ORY 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 HERE Y G1AltT A PERMIT
to Carleton Funeral Home, Inc. (E.W. i son) ;Judson Falls, New York
the Funeral Directeor to hold temporarily and inter (Address)
(Undertaker or person having charge of corpse) the body
Dated_Q.Ctolrter 10, 66 ( t remove, of piiee�disp�ose po�f [state how])
19 (Signed) . ) `�'x.. .SL1�..?
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.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of- -_(E:2-. waa 19C'. -,
(Interment)or Crematl tt)
c Ar
(Name of Cemetery, Crematorium, etc.)
Section Lot No).r Grave No.6
(Signed) <�..• wa.,
(Pers(n in Charge)
Address 'L f ..E:: L G
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict 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 required, under penalty,
to report violations thereof.