Baker, David -NEW YORK STATE DEPARTMENT OF HEALTH-`" lilt
Vital Records Section Burial - Transit Perm t
bi Name First Middle _Last Sex
iv
A/ ,� l
Date of Death { Age If Veteran of U.S. Armed Forcesy� /G
����C�( ((�� War or Dates /4/3- � T.J-
14 Place of Death Hospital, Institution o.-
Z. City, Town or Village:f S /9//s / Street Address 4/6//(,S/�/}/,5 ///
III
Manner of Death0Natural Cause �Acciident Homicide Suicide �jndetermined / Pending
I Circumstances Investigation
tii Medical Certifier Name /.� E.4 C/(_ 4 ,4 Title
Address - /�-S /7/ /
Death Certificate Filed District Number Register mber
City, Town or Village f�//
_. OBurial Date �^ Cemetery or Crematory
[]Entombment �� / � f/% L'/ell C14* %'a
Address
> ' remation U S4�
Date Plae'e Removed
❑Removal and/or Held
and/or
Address
M Hold
Date Point of
Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration/Nu Number
e ( %242
Name of Funeral Hom ie/4 67 7cae6Z /41 c 61/ 9V
ligi Address
Name of Funeral Finfi Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
Ili
d" Permission is h reby granted to dispose of the human remains describe above as in. ted.
Date Issued Registrar of Vital Statistic C' e_.4Y, Mi. L R./--'C,
(signature)
1110 District Number `5-611 Place 6/c7j5 /94 /J /)Ai
I certify that the remains of the decedent identified above were disposed of in accordance With this permit on:
Z /^
III Date of Disposition 1/. cj r/6 (.Place of Disposition P+nov,1 w C.rt v c.4v't,v»-.
(address)
LEI
co
cc (section) (lot number) (grave number)
Name of Sexton or,Person in,Charge of Premises L IN t` f \O 0la
of
/��, ` (please print)
Signature A/A-fiF Title (Re Vh s +'
(over)
DOH-1555 (02/2004)