Baker, Ada I
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First A l Middle- Last ? e*S —
Date of Death- Age If Veteran of U.S. Armed Forces,
�a,1 . , a b 1 I -`r War or Dates
)., Place ath //_� Hospital, Institution or
Z City,T own r Village [O A;a"� Street Address
Manne� Death 2 Natural Cause E Accident E Homicide Suicide Undetermined Pending
LCircumstances Investigation
W Medical Certifier Name I f� ,, Title
4 I�Gharr) U . l r e., /11 D.
Address /
CL.t-Ccr S-L. C,': , N 1 1 .kg),Z.
Deat cct icate Filed ibistrict Number Register Number
City, T wn Village .1)r,'(1 553
— Date Cemetery or Crematory
Burial �4A 3 ; (D ,'.i c I/,c,.., Ge,..,t-E of
Address f
L Cremation k-A,•e-Cd1S�L-kr N,
Date 0 1 Place Removed
Z '—'Removal and/or Held
V and/or Address
0 Hold
Q Date Point of
nElTransportation Shipment
E by Common Destination
Carrier
—Disinterment Date Cemetery Address
__ Reinterment Date Cemetery Address
Permit Issued to "'�jjam� ,--- C Registration Number
Name of Funeral Home��t'Je.v,SMo rc. 1',.kler ki..r,ci _I—, dC7�`"Z
Address 7 // 4,l
>��eo,Ia1 Ave ,,. �,r ,k�� /U. l :41(J�d.-
Name of Funeral Firm Making Disposition or to Wham
" Remains are Shipped, If Other than Above
2 Address
Lu
Q
Permission is hereb granted to dispose of the human r ains scribed ov s ' icated.
Date Issued / / ii Registrar of Vital Statistics �- ,�1
a re)
District Number 5-5 3 Place (7;F -A-- 1-` i Aie,..' / r k/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i-
wDate of Disposition fay. `1, ZOi0Piace of Disposition 1 ,A4 LL - Crc orhit_
2 (address)
t1J
CC (section) _ (Irt number) (grave number)
dName of Sexton or Person in Charge f Premises ns+cly— @�^/��
�yi (please print)
w Signature Title (1?E M -i OP
DOH-1555 (10/89) p. 1 of 2 VS•61