Baker, Edward NEW YORK STATE DEPARTMENT OF HEALTH- *. < 4 �41
Vital Records Section Burial - Transit Permit
1`> Name First Middle . . Last
Mii Date of Death.. Age / If Veteran of U.S. Armed Forces,
° ,L a Li ao C� fo0 War or Dates )`t67-Oct
.- of Deat Hospital, Institution or
own or illage 66.-1‘.t--1- a- Street Address 6 z I.
:� anner of Death[3 NatOral Cause ❑Accident 0 Homicide 0 Suicide Undetermined �— Pending
Circumstances — Investigation
id Medical Certifier Name AATitle
Address
eroAL0..., ,sue. -k-4.....,„\,1 d
iliiiill h•Certificate Filed 01 District.Number Register Number
i , own or Village p .Cell\--
c,O j_ 3 S�
Date _ Cemetery or Crematory
❑Burial J L.Z 5 'L �;n"-c" C'e,".47,A--4-....
Address
a Cremation w�eA.sb xe3 I /t-)e-- Jim
Date Place Removed
0 r—I❑Removal and/or Held
17.1 and/or Address
Hold
0 Date Point of
NQ Transportation • Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<; Permit Issued to . Registration Number
»: Name of Funeral Home zv�i,�5,,,,.g.c 'J ,�crk. ( )�3An.) J a a `r$3
:.t Address
'iiig —7 C)I1et".0-r A e r.-;d4-- Al trf jjk g d,-)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t .
4
Permission is hereby granted to dispose of the human remains described above As in aytd.
< ! Date Issued 7/ 4. 471� �d 6. Registrar of Vital StatisticsliL '
(signature) �, / y
ii District Number 3 G 0/ Place C_ i p C�L.-7,-i"'�' A), / .
I certify that the remains of the decedent identifi above were disposed of in accordance with this permit on:
f*
WDate of Disposition 7/d.i:,., '.., Place of Disposition Pitwilc,.- 11 c'vr-� (.-•C‘{ v
(address)
i1!
(1)
II (section) (lot number) (grave number)
DName of Sexton or Person ' Charge of Premises A r 1 ) n n.�z�r •
g ('L
(pleasent)
Signature Title CI\e'r^r- 'l-
(over)
DOH-1555 (9/98)
1