Baker, Verna NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mae
Last Sex
Verna Baker F
• Date of Death Age If Veteran of U.S. Armed Forces,
01 /1 0/2 01 5 7 7 War or Dates
A Place of Death Corinth Hospital, Institution or
City, Town or Village Street Address 17 Holmes Road
Manner of Death�Natural Cause 111 Accident ❑ Homicide ❑ Suicide 0 Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name David Mastrianni TitleMo
Address
3 Care Lane Saratoga Springs,NY 12866
• Death Certificate Filed Corinth District Number 4 5 5 -j Register Number
Ci Town or Villa e ?•,.
❑Burial Date 01 /1 2/2 01 5 CemetFry-or Crem '4'ry pi nevi ew Crematory
0 Entombment - -
Address 21 Quaker Road, ! 12804,, .4®Cremation _
Date er
���❑ Removal
and/or Address
Hold
Date Point of
�. ❑Transportation Shipment
by Common Destination
Carrier
x• ' Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Densmore Funeral Home Registration Number
Name of Funeral Home 00448
• Address 7 Sherman Ave, Corinth,NY 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
44 Permission is hereby granted to dispose of the human re ains described Love as indicated.
Registrar of Vital Statistics r
Date Issued /-A2 -.2e 1,5` g 0-o.„ E . 4 • a c(
(signature)
f District Number 1 ,5;63 Place Q.A_)\1_,,-.1) (\
=4- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition I/(4JI3- Place of Disposition 1CrncaAA1 6 z' ' .
(address)
(section) gj(lot number) (grave number)
Name of Sexton or Person in Charge f Premises Uyhr`Apt-
(pl ase print)
Signature4 Title mot ( i,
(over)
DOH-1555 (02/2004)