Baker, Patricia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial . Transit Permit
Name First D Mi dle Last Sex
i cir)Z i C I / ,•�'U . �Y3-A b'vt._ l-c/7gt Li
Date of Deat ) Age If Veteran of U.S. Armed Forces, )
6, /2-3-7/6, cP/ War or Dates "I//a
Place o 9-ath Ho pital Institution or
City, owl., Village Street Address &3 C, i`'iP L..14'ra-r)-L_ r<439_-&�
. Manner of Death Natural Cause D Accident D Homicide Ei Suicide ElUndetermined El Pending
t Circumstances Investigation
a.
tu Medical Certifier Name Title
0 ,J u 62,141- D C I A.) 2-C
Address
Death Certificate Filed 1/ DistritAtM
i Re - r Number
City, ow r Village /[0 a.L14v
DBuriai Date Cemetery Cremator � f
& IZ71 ' "JeI16')
❑Entombment Address 3
®.Cremation C 0 ek Lam n- I Ucis (3 i-i j Ajy
Date Place Removed /
Z ri Removal and/or Held
and/or Address
Er Er Hold
Date Point of
0❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to } 1 Registration Number
Name of Funeral Home 1 O \e r cc \ HO t (7)11 Q
Address
11 Lc.-Sal e - C - C c.:C:::r` t 1 t N 1Zh G 1-1
'= Name of Funeral Firm Making Disposition or to Whom
0#i Remains are Shipped, If Other than Above
2 Address
CC
W
13 Permission is e eby granted to dispose of the human remai escribe a ov s indicated.
Date Issued - dae Registrar of Vital Statistics / L ( f
qc-bg___ (sig atu )District Number Place ., .0n //S 0`4 1� ocaa l . OD)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
its Date of Disposition 6/Zq/f(, Place of Disposition t01 .-./ grrnwtfJk-%,
2 (address)
UI
UM:
(section) j (lot number) rl (grave number)
>g ��(,,� J
G Name of Sexton or Person in Charg' a e
of Premises , 4314, "
( lease print)14,,..::,:. SignatureTitle cizeti 1(
(over)
DOH-1555 (02/2004)