Baker, Jr. Roy NEW YORK STATE DEPARTMENT OF HEALTH 6 t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
• Date of Death V Age If Veteran of U.S. Armed Forces,
�= � V/ o/l S2 War or Dates y 5
Place of Death Hospital, Institution or
itz1 City, Town oiillage3 64-)ei' (`' 17'4 L -- Street Address �Z i''- Ceil719it� 37 __7
a Manner of Death Z Natural Cause ElAccident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name , / Title
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Address 1
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Death Certificate Filed District Number Register Number
City, Town or Village 3
❑Burial Date /, /i i.// 0 ti Cerry or Cremator J
❑Entombment Address
,Cremation 6'1 62cw/9-/«rz /eo Ad, v>(4r-e ' s ba" /l/Y /Ga E-'O 3
Date Place Removed
Z❑Removal and/or Held
and/or Address •
t Hold
U)
O Date Point of
to❑Transportation Shipment
O by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home // /1 tu✓iPed /t129/1 ' _/.7 - .0 S-;5 $—
Address/ > T / ,` 7
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Name of Funeral Firm Making Disposition or to Whom /
Remains are Shipped, If Other than Above
• Address
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Permission is hereby granted to dispose of the human remains descri ed above as indicated.
in Date Issued /e2�e2._—// Registrar of Vital Statistics �_
(signature)
District Number 5766 Place ,eZ �_�, . 44,X• I certify that the remains of the decedent identified above were dispoed of in accordance with this permit on:
ta Date of Disposition ptC iy1 ZoLV Place of Disposition (;:i)b 1/14) Cwf•efeli ,
(address)
co
cc (section) 4 _ (lot number (grave number)
a
(
G1 Name of Sexton or Perso in Charge of remises cy�p ,Seim it
�YI (please print)
iLi Signature Title CVZ it tit
(over)
DOH-1555 (02/2004)