Baker, Jasmine if Lay
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Micidie Last Sex
Jasmine M. Baker Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 29,2011 73 War or Dates
Place of Death Hospital, Institutionjirondack Tri-County Health Care
Z City, Town or Village Johnsburg Street Address Center
pManner of Death X Natural Cause Accident Homicide f 1 Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Thomas Warrington
Address
HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 (3 3
❑Burial Date Cemetery or Crematory
Entombment August 30,2011 Pine View Crematory
Address
Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:a Address
ILP
Permission is hereby granted to dispose of the human re a' s dee rib ab s indicated.
Date Issued OZ O�C1 0?°4 Registrar of Vital Statistics L.-
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition %tat:11$ Place of Disposition EA, Ceon A,_
(address)
co
re (section) / e (lot numbe (grave number)
Op Name of Sexton or Person in Charge of Premises f 11110 '
W ( (please print)
Z /
Signature 7 _ Title Cq KITT(XL
(over)
DOH-1555 (02/2004)