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Baker, Jr. Donald NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section I Burial - Transit Permit Name first ' kliddle Laltak, Sex Date of eathei A e If Veteran of U.S. Armed Forces,V IlOpi:: 6749/0— � War or Dates Place of eath c /4� Hospital, Institution or n � g City, Town or Villa e�,%, ,� F'�-u .. Street Address b© f ,,// / Manner of Death ..Ql` �jf�y l Natural Cause Accident Homicide Suicide Undetermined Pending l Circumstances Investigation la Medical Certifier Nam p ,, Title Death Certificate Filed District Number �Register Number City, Town or Village /' � ��� €> ❑Burial Date Ce tery or Crematory ❑Entombment Address Cremation a`.,/ it, -n l to*ye\ Date Place Removed Removal and/or Held and/or Address Lt CA Hold 0 Date Point of ta Transportation❑ p Shipment G by Common Destination Carrier Q Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to Registrationumber Name of Funeral Home (1C3 K u flea, R��n✓ 3�- („�E ( LO� Address '' L 'rocdsu � -4- �1� t .� -J • (awl in Name of Funeral Firm Making Disposition of to Whom Remains are Shipped, If Other than Above Address la 5 . Permission is hereby granted to dispose of the human remains describe above as• ica,, piii Date Issued 511 Y Registrar of Vital Statistics „46411- (signature) gij District Number 6 t 0 j Place s:::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k � ILI Date of Disposition V3u/g Place of Disposition -R r i Utw Crt jat_ tii (address) 0 l (section) l/ — (lot number (grave number) Name of Sexton or Person in Charge of P mises ih► A. {V41' (please print) >: Signature Title Cis Wl frT O . (over) DOH-1555 (02/2004)