Tucker, Ida Belle - " . *-q I
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Zk r
Date of Death 4 Age If Veteran of U.S. Armed Forces,
L War or Dates
Place eath � n�i Hospital, Institution or 4—La"vc,
Ci ow or Villa e llA 1Street Address
Manner of Deat—hM Natural Cause []Accident [--j Homicide Suicide Undetermined Pending
LU Circumstances Investigation
Medical Certifier Name A - Title m t I
zhamo
I IS I("i a 10
Address
-
Death,go,dificate Filed , n ^ District Number Register Number
C' ow or Village
ak
❑Burial Date jj ; Cemetery or Crematory `
❑Entombmenti— D1 a 2U2o'
Address
Cremation QUk if KC ° I/ (',
Date I Place Removed
Z❑Removal and/or Held
and/or i Address
Hold
Date Point of
®Transportation Shipment
by Common Destination
Carrier
Disinterment Date 1 Cemetery Address
Rsnterment , Date I Cemetery Address
i
Permit Issued to Registration Number
Name of Funeral Home Baker Funeral Home i 01130
Address
11 Lafayette St., Queensbu f, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CL
Permission is hereby granted to dispose of the human r 1 in$ °scribed above as indicated.
Date Issued Registrar of Vital Statistict
' (sig store}
District Number Place /�,JU
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /-,2 -.2c," Place of Disposition �Je° ✓ �'1�irt roc/
(address)�—
0 (section} ' (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
Signature _ Title
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) i 013)8 F5.
i
Receipt
Human remains of delivered on , 20
t
Pine View Cemetery Representii}g'the funeral home named on burial permit 1
Official Funeral Directors Reg.or License#
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