Jenkins, Anthony NEW YORK STATE DEPARTMENT OF HEALTI1 ,r
Vital Records Section Burial - Transit Permit
Nam_ a First l Middle Last Se,
Date of Death // / / Age If Veteran of U.S. Armed Forges,
3 /)l/s' Dates ,j/41 a of Death ospital, I stitution or
a Ci own or Village QL,e-ni-C f;g-(,C,5 Street ddress Qt, „j_s FeZ,t s"
Manner of Deatt 'r atural Cause O Accident ElHomicide El Suicide O Undetermined 1-1 Pending
Iiivv����' Circumstances Investigation
Ca
Ili Medical Certifier Name Title
I L L :il,i j 9
Address
th Certificate Filed District Number Register Nu er
Ci own or Village l L e''„3 j t`-3-Z,{, . 01 I ZZ.
in Burial Date /15-1/S--
Cemetery r Cremato
---- ,,.)(7 eA-J
O Entombment ��
Address
:::1:) Cremation 1 C-.) /t y
Date Place Removed J /
gri O Removal ' and/or Held
tt and/or Address
-5 Hold
Date Point of
1 O Transportation Shipment '
C by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
`>< Permit Issued to Registration Number
Name of Funeral Home Maynard D.Baker Funeral Home n i l 3 a
>> Address 11 Lafayette Street
Name of Funeral Firm Making Di4,oiar8O4
Remains are Shipped, If Other than Above
Address
1
L
Permission is hereby granted to dispose of the human mains describ above as' dice •.
> i Date Issued . Registrar of Vital Statistics
? (signature)
District Number 706 i Place
I certifythat the remains of the decedent identified above were disposed of in accor '.72Y.
•
dance with' permit on:
i, Po
2 � �p
at Date of Disposition 3)lI l6-- Place of Disposition '(i�t Ua„i C' ty,...,
a (address)
aj
Ca
(section) (lot n ber) (grave number)
Ct
Name of Sexton or Pers n in Charge of Premises iry 3Au*
, (please print)
Signature Title t ittik1
(over)
DOH-1555 (02/2004)