Baker, Dorcas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First. Middle Last I Sex E
�OC�AS Oc -A 16AIC
si Date of Death I Agegr.) ; If Veteran of U.S. Armed Forces.
3 /'7 I/ `J "Il1 War or Dates
44 Place of Death I Hospital, Institution or
>Z City. Town or Village 'co C 1--3-6.�) Street Address %F. \ v`DSC tJ
pManner of Death�Natural Cause 0 Accident 0 Homicide Suicide Undetermined ❑Pending
I Circumstances Investigation
'Fiji Medical Certifier Name k/ Title 0
Addi:uress
�i o-050 o3 foci. L c)L-"-J 11),Q SC)i C`--)-'- vIR(D--
Death Certificate Filed I District r I Register umber
City. Town or Village �o ��w�2 1 D'D5 I 1p
��--//' i Date ( / I Cemetery or Crematory
I.�Burial j S I /� Laois--C � 1 �� n c , E \J 1/41,-‘c Ee 1
— s Address
'
: _Cremations v*lc Liz_ :c LX
vt.c t...›Si vQ i
I Date I Place Removed
Z —Removal and/or Held
- —and/or ' Address
t= Hold
0 Date Point of
n Transportation i Shipment
0 by Common Destination
Carrier
Disinterment Date l Cemetery Address
— }
Reinterment I Date Cemetery Address
iiIiii Permit Issued to�a .� _ l I Registration Number
Name of Funeral Home , 6/-4 c::�-� -�;..-);;1 a /i4 NC I 0 r 130
IIIIft Address ,-
j Ij (�1��!?jj'L7 iLr 4-�i t�\/1-'f.=t�.tiS u L11LC-' I;� �l l L�' i
on Name of Funeral Fja'm Making Dispositi or to Whom > ' /
Remains are Shipped. If Other than Above `
Address
LU
4
Permission is er by granted to dispose of the human ains described bove s indicated.
Date Issued 7 5 Registrar of Vital Statistic • va
0
�[n -7 (siL'�,,Lh l�,�
ure) wi
District Number. 1 � Place /0 - -6 kith
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
EDate of Disposition 5/1 4/1 5 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
LIJ Sec. 1 , Hudson 4F 2
cc (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premi s Connie. L. Goedert
Z (please print)
W Signature 4/26' . -` ?c ui, Title Cemetery Superintendent
1
- (over)
DOH-1555 (9/98)