Baker, Orpha V- ?cal.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First O r h o.._ Middle-D Laster�� Sex
Date of Death ,3 1 2.1_4 1 Z(Ol Age q0 If Veteran of U.S.Armed Forces,
War or Dates
Place eath r `
} C u�.er,. Institution _ S i n�
own /
Manner of Dear&atural Cause ❑Accident ❑Homicide ❑Suicide �Undetermined Pending
-51 Circumstances Investigation
. Medical Certifier Name Title
�' psi n SOCo1® M.0
CI
Address / V (Qa
VDeath e Bled� ���1 �i� D; 4" t �Number Kerbs r umber
5- i Town c� t
❑Burial Date b-Q.C9-c�0►�j Cremat I ..
ii: Address ncl , C
: remation Qll�1k k e r atl b
n Sl t fl /, 1 a� C
Date Place Removed
g❑Removal and/or Held
ri and/or Address
Hold
- :iDate I Point of
❑Transportation Shipment
by Common Destination
Carrier
: :�Disinterment Date Cemetery Address
0 Reinternent Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Hay/lard V, maker Fu.nercz/ J f ome. 01130
47
Address
/I Lary i to of. , { u:ee n /a-tad E 11 e w Voc1k l a gog
x Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the huma r ains described above as indicated.
Date Issuer ( (9 Icy► Registrar of Vital Statistics I � Q. ( L ) 1\---
' (sign re)
District Numbet(J(9 Place ) O 0 '(" CD —„
is I certify that the remains of the decedent identified above were disposed of in- dance " this permit on:
i*
Date of Disposition f3- )h-/.3 Place of Disposition
address)
lO
fa
IE (section) of number) (grave number)
QName of Sexton o erson in rge of Premises D� O(a Ijfin
�/�"`-� (please print)
g:? Signature Title 04.--44-, 7's.
(over)
DOH-1555 (9/98)