Baker, Charles an NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle I ast I Sex l
��,r� eS A• �ct li e.`r I r",
<< Date of Death i ��,nn i Age �l I If Veteran of U.S. Armed Forces,
o 1 1UCA ) 15 I �V i War or Dates N )4-
,,,,,p
1 P ace of Death I Hospital, Institution or
, Town or Village G-1.Q..!()S F I‘S I Street Address GiLns S\1S H eidim
Manner of Death 4 Natural Cause n Accident n Homicide 0 Suicide n Undetermined Pe ding
ILI
Circumstances Investigation
Medical Certifier Name Title
ri C�, �\C>Q f - *\aI Rt)
is Address
\ .[/\ Ca y gad c ,�0fy Nd 14)9
�`.. ath Certificate Filed I istrict Num er /
Town or Village G l Q) 1 c. ! lD el giste ' , ;er
Date _ I Cemetery or Crematory y�
Pli Burial A \p I I lQ I I 3 1'\.-. t Y010 n
ddr s5
C Cremation ( l�` I
fl❑Removal Date / ;/Place Removed
and/or and/or Heid
Hold Address - -
l Date I ?;int.of
N n Transportation
j Shipment
a by Common f Destination
Carrier
0 Disinterment Date I Cemetery Address
I j
Q Reinterment Date Cemetery Address Ii(
>; Permit Issued to
Name of Funeral Home 13ccker �C uierczi //0me j Registration Number III
iMi Address l; /� I 011 �(�
LCCrC� � e , , �Jt,lt(,�SJDCr i ; /Ut'�G 1U, lL v
Name of Funeral Firm Making Disposition or to Whom `/ � ��y
-F Remains are Shipped, If Other than Above
44 Address
<;:> Permission is hereby granted to dispose of the human remains described above as indicated.
<': Date Issued i 0 l i 3 / 1 5 Registrar of Vital Statistics
_ (signature) v�
<' District Number , 610) Place G S t LA,\ / " t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 0/1 6/1 5 Place of Disposition Mt. Herman Cemetery, Queensbury,NY
LLI
2 (address)
IA
Baker Family Plot
D Name of Sex or Person in C rge of Premiss (section) (lot number) (grave number)
Connie L. Goedert
Z _B„ (please print)
4! Signature ,/(_/j Title Cemetery Superintendent
(over)
DOH-1555 (9/98)