Baker, Rexford NEW YORK STATE DEPARTMENT OF HEALTH g'iQ
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
- PeX c.)c6 w;11 vum ►a r 1�
-Date of Death Age If Veteran of U.S.Armed Forces,
Z.I a-1 Iaa13 War or Dates N li
. Place of Death Hospital,Institution or 2
City r Village L 4d i Street Address 7 l er 13 r4 ), ?tad
Manner of Death Natural Cause Accident ,Homicide Suicide n Undetermined Q Pending
Circumstances Investigation
Medical Certifier Name Title
Ex-', C P ,l\ e i-AD
Address
•
;A -.1UFA'1S \\S �C I4 C\\ I 1 N
k Death - 1 cate Filed Dis Number �J �j� 1 Register ber
, City •rvillage e1p1--t3v1 Lo.n..h+ `Jll� �JU o
' Date Cemetery or Crematory
El Burial iZ )3Oa
., ,d )�J p;ne Vim Cr-ema ar
Address � /, f
::; Cremation pe�C r y f� �J
Date Plate Removed
8❑Removal and/or Held
0, and/or Address
Hold
Date Point of
Q Transportation Shipment
a, by Common Destination
Carrier
D Disinterment Date Cemetery Address
�]Reintem�ent Date Cemetery Address
r Permit Issued to y f Registration Number
Name of Funeral Home Hs card 15, Zct�`ec F eca,/ Home. •113•
4 Address ,, La a q -e . , btit.Q.Q1nbu-rc j ,)e w L/or)i l o?SUy
ilia Name of Funeral Firm Making Disposition or to Whom
t' Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remai s descri ve as indicat .
Issued D R istrar of Vital Statistics
Date a �0�3 eg ��C
, (signature) Ll/V 4/6 , .)'
A/District Numbec���� Place `V-
..:::
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fr n �)
6 Date of Disposition la/31(i j Place of Disposition i.cA .,� CA4frd .
2 (address)
141
CC (section) Opt num ) (grave number)
Name of Sexton or Person in Charge of Premises n'�q low e"•'/1-
Z (please print) V
g
Signature L.- Title C204.41-012-
(over)
DOH-1555 (9/98)