Baker, Barbara r , iitL 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . Burial - Transit Permit
' Name First Middle Last Sex
Da e (f Deat Age If Veteran of U.S.wArmed Forces,
`S ao- J 1 War or Dates "V
Place • Death Hospital, Institutio, •r
City, ow or Village Dh t15b u r Street Address A i ,T(`, C
Manner of Death f'�I Natural Cause ❑ ' cident El Homicide ❑Suicide ❑Undeter fined ❑Pending
4�.� Circumstances Investigation
ao
Medical Certifier Nam- Title
A•• ess
D r `C'J
Deat - - ificate Filed Di.g.ie Num .v Register Number
City Town •r Village 10 A e _ _
4Lte ❑Buria s ay Date - etery or Crematory
Iii
❑Entombment Address ` Jai hi, s , /
LO Cremation / • A ,A _ t
Date r Place Re •ved
ri:i El❑Removal and/or Held
and/or Address
Hold
Date Point of
-- ❑Transportation Shipment
=f= by Common Destination
Carrier
ii .❑Disinterment Date Cemetery Address
i❑Reinterment Date Cemetery Address
it Permit Issued to , Re•istration Number
Name of Funeral Home IN_ A 0_ = a ryUL__ r
Address LI Z O 4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereb granted to dispose of the hum. emains describ:,• ab• as in./ ated.
ilk Date Issued 413) )1 Registrar of Vital Statistic _Jj'4/ / i •
4,4
lit (signature)
District Number L 55 Place o�n 6 tif n • r
4.4 I certify that the remains of the decedent identified above were dispos-• of in accordance with this permit on:
Date of Disposition $f/g)n Place of Disposition l ircwN 6.,.0.40=.,.,
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises a
-- (p/e e print)
yrei
kw Signature 2 Title lvifiien
(over)
DOH-1555 (02/2004)