Baker-Wolfe, Linda NEW YORK STATE DEPARTMENT OF HEALTH * # S J
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
/AvD,g A4 : i2Ag 6it — WO F ff 1AL
iiiiii Date of Death Age If Veteran of U.S. Armed Forces,
�01/ 6, o2O jf 3 War or Dates
• Place of Death Hospital, Institution or //Y. t vAwSeeic." Ape .
ty,4 o ge -IOW". LAK8 Street Address AMC.- /t? CY C'btn2=.2
5 Manner of Death i Natural Cause ❑Accident Ei Homicide 0 Suicide 0 Undetermined ri Pending
41 Circumstances Investigation
Medical Certifier Name Title
J g Jv 5e22.-4 JQ 11.yo,
iiial Address
mo
/RS* l9tD �, nil /r O, /4 /° r✓i, 5I 1
Death Certificate Filed District Number Register Number
1 CitY,VIM' . " _.e 70,1',A 44K( /6S0
Date Cemetery or Crematory
Cl Burial A/O(/ q, c O`/ /'°/NJ t4'd&.-/ .' ?gyp
Address
LIN Cremation o2./ "e.../ %e-ti., 21 Sox ',t,l c zi'3 i 1v7
Date ` Place Removed
fl❑Removal and/or Held
-- and/or Address
= Hold
0
O Date Point of
4040 Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MB,G°GgA,K, but O/O Ry
ipiii
Address
Iiii ?21c SAR-A NAc, Ac/v'' /'LAIckl. Arno, ivy / --q y(
Name of Funeral Firm Making Dispositiorl'or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remai described above a in ated
P, Date Issuedl�` 7-•�/ Registrar of Vital Statistics �.�.L-C,tp �-" ���.
" (signature)
'``>' District Number 4$v Place iv-,..) Dr 7-1.)iDP,EJZ- LA/ce-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f- Date of Disposition ii � t iit Place of Disposition • Qc..tthi..j 60wq f o r ...
(address)
LW
U)
CC (section) dr
(lot number(�)- (grave number)
O Name of Sexton or Per on in Charge of Premises ,s-1 �+'r 41ritt
i.
Z (please print)
94 Signature AIL, m Title ae. lO`e,
(over)
DOH-1555 (9/98)