Baker, Donovan NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Viltage, 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. �,��
l Town, Villa Rgisered No.
Dist. No. \ County `-'��'�'Y1. or City �.) V'tn 0...
(If city, give str?et?address)
Name of deceased � ... ...... . ....... `ac 5:?p..l\ Veteran J.. \K.) "
(If veteran, give name of War)
Single, married, widowed,
Sex \QQ or divorced (write the word) V\0.1 ..Date of Death \c' 19 `-1^
Age ears .Months Days , Birthplace SI ('----,) U Z
Cause of Death .... ‘,--A (:}--. .GNN\
Certificate was signed by r.t- ` G-1u� M.D.
Address ..a... �x$L nIct: A•
.
,�
Place of Burial (or Removal) .... . , , �'s- ..Na
(If body is tort e temporarily held, (ill in space later)
Cemetery ,.t" * ..) Date of Burial C -Q(, n. 19 -1 3,.
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT `2
to ..................cl,l.,(�.1.. � -��\..v. \A�`�`-�,. `\Lk ' N Lo Y Tts�/�, v
� (Name) ( .daressr. J.r.. 7
the ......1ek Y1 .kZ ^ to hold temporarily and S...Q-v ---\„ the body
ndg aker or,personn having charge of cOrp�e) (Inter, remove, or otherwise dispose of (state how))
Dated Y� l
` �lw -Qr lJ (Signed) ... / .
This Permit is sufficient for the Removal (and Interment or Cremation)of a bo ?']a to any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit ermit (VS No. 62) is required.
FOItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date 2-4 '"`,/ was V/ 7 19 3
(Interment or
2 , v.--
(Name of Cemetery, Crgmatorium, err_1
Section c-(�, Lct No. / C-- Grave No.
, �a
(Srgny�l -r ._,_
(Person in Charge)
C C `E'r"L'�.
Address �� }4 i�'"�'° �
�./7.zL C...�2 d-;,--z:4--j
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 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 OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.
DAM,
,.� Lot No. 7 c
Address 63 Main St.. West `'lens Falls, N.Y. Section No
Owner Mrs. Pauline Baker Plot unadilla Ext-
.
Date 4/9/?3
inn Superficial ft. @ t2_00 per sq. it_
Location B.Onded on the North by Vacant. East by Path., South by Saunders, West by- Vacant
Corner Posts
Remarks
Deed No. (and changes) 3259
Payment Record Paid in gvli 4/9/73
10F: -•
Form No. 01
Record of Interments
1 I Donovan E. Baker ( h/9/73) 5
2 0p1.., fleaC c?- I.C'1•a►a ►� �S i
3 IAA ) Cot. F e r 7
4 8
SJ
A -Al
V
E o j
114
,, 4
NAME Baker , Donovan E.
(4!)
Age: 47
Cause: Coronary Occlusion
Lot Owner: Pauline Baker
Lot # 7-C Unadilla
Grave # 1
Case # Concrete
Died: 4/6/73
Interred: 4/9/7 3
Undertaker: Maynard Baker , WArrensburg