Baker, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom' 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered o. /l"
e. Town, Village
Dist. No.OZa/ � Co ty � .. or City
If city give street address)
Name of deceased -CI_. - Veteran ,
(If veteran,give name of War)
Singl arried,widowed,
Sex Ma....22- or divorced (write the word Date 4f Death /7 19__77
Age 7,2,.., Year . _._. onth Days rth)lace
Cause of Death 71 / %�G�fl�-m.G„/
Certificate was signed b > 7 tV.t-1 Q &. ez -64 '^. M.D.
Address (/
Place of Buri or Remova ) _- __ 1(17--
(If body is to be porarily hel( ill in spac later)
Cemetery ..A./ —,____ ____ ___ Date of Burial @ 19._7
(If body is to be..temporarily held, fi 1 in space later)
The CERTIFICATE OF DEATH containing the above stated particulars. having been presented to me, of er careful examination,
the same gearing to be COMPLETE, CORREC , AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regi tion, have recorded it in my Local Rec rd with the above stated Registered Number, and on the basis thereof I HERE-
BY G PERMI •
to - _ � � c c'<,C / /J( (�/G��111.(irt�
am (Address)
the to hold temporarily and the body
(Unlertaker or ers hav ng charge of corpse) ((n eme, or o erw'se dispose of (state how))
Dated 19 ..* (Signed) -"
Lac 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. 6,631 (8A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of a was 19 77
(Interment or Cpeir[atmm'
(Name of Cemetery, Cate= torium, etc.)
Section 4-e.-4-ZeLot No. i( Grave No N3
(Signed) `L
(Person in Charge)
Address
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
UNDERTAKER 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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.
LF)
Lot No.
17.,
Address R 1 n Ride Glens Falls N.Y. Section No.
Owner Irene W. Baker Plot One ida
Date .2/19/79
100 Superficial ft. @ # $375.00
Location Bounded on the North by Road, East by Path, South by Vacant, West by Vacant
Corner Posts
Remarks
Deed No. (and changes) 1520
Payment Record Paid in full 2/19/79
Form No. 01
Record of Interments
1. .� I 5
2.. ' Irene Wilson Baker 4/27/90 _ 44-° `-qo 16 !
_ ¶hn .T_ R2k r ( /2n/79) `?'/Lk9 7
4 1 18
✓ it(-di// ,
17-1
x X
1
i
RAKER, Thomas J. (II1i..j)
Age: 72
Cause: Myocardial Infarction
Lot Owner: Irene W. Baker
Lot f 11, Oneida Plot
Grave # 3
Case: Concrete
Died: 2/17/79
Interred 2/20/79
Undertaker: Potter