Baker, Clarissa NI
NEW YORK STATE DEPARTMENT OF HEALTH' . 91111 R
Vital Records Section Burial - Transsit Permit
Name First /, / Middle Last Sex
C�G-A-IN': Ss� OA j
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Date of Death Age cy If Veteran of U.S.Armed Forces,
7,a°i S-- g cl War or Dates ,1--
1- Place of Death Hospital, Institution
W City,Town or Village City of Albany or Street Address
UManner of Death Natural ❑ Undetermined ❑ Pending
i ® Cause ❑ Accident ❑ Homicide ❑ Suicide Circumstances Investigation
V Medical Certifier Name Title
o `�dt w,,, .e LJ M�J
Address`± � L N` !t�
2) f\k -3 SGo-/ LA Vc 4 4A 1 / kaJ
Death Certificate Filed District Num�L er Register Number
City,Town or Village City of Albany 1 101
Date Cemetery or Crematory
❑ Burial a/ 1 /aol 5J ,.,, e frx.--- 6-A-1-4v r K...
Address
Cremation
Date Place Removed
Z ❑ Removal and/or Held
_ and/or Address
1— Hold
N
0 Date Point of
NTransportation Shipment
❑ By Common 0 Carrier Destination
❑ Date Cemetery Address
Disinterment
ElDate Cemetery Address
Reinterment
Permit Issued To - Registration Number�
Name of Funeral Home c=--�/ - �'(r ^`'—J/,' n.S. 4-o rc 1j0 `"` /
` 0
AddressA.,,„„, rc
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Name of Funeral Firm Making Disposition or to/Whom(
H Remains are Shipped, If Other than Above
2 Address
re
W'
0- Permission is hereby granted to dispose of the human remains des ibe : sincaPd
Date X / ' / - 5 Registrar of Vital StatisticsIssued ignatu )
District Number 101 Place Albany Police Department of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
li Date of Disposition '21 II I IS Place of Disposition gel C-Ndo'N...
LU (address)
W
N
-_ (section) (lot nurar (grave number)
0'
G W Name of Sexton or Person in Charge of Premises /fit
(please print)
Signature A T Title CAx_mit Abf
(over)
DOH-1555 (9/98)