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Jan 10 12 03:03p Baker Funeral Hama 518 7F1 0044 p.2
NEW YOFtK STATE DEPARTMENT OF HEALTH Burial - TransitGt't'11i
Vital Records Section
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Name First LeCX.h Middle t_a5t Sex
en .mnC.CT F
Date of Death ` Age p(3 If Veteran of J"S-Armed Forces,
'' 2. �� O t war or Dates
•�'" Place of r - ...-
r .Sbt.Ar rrsiitutior
;sJ Manner of Death 0 Natural Cause J Acctdeert U Homicide 0 Suicide n Urideterrnined J 0 Fe riding
Circumstances Invest+ ation
Medlt ai Certifier N ^- Ti A
.4 - — are �trll Warr ► nothrl Title I
: Address r!a ,;; 0) �d J.
�j�`r+h C'ee k, )315-- -
Dee rtificais Fi _ci - District Number -- - Register:slumber
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0 S arisi ; Cate--�'0..C•1. (� a 0!a rematcry.3 tf-1►INC-: __,______
❑Enuombment"Address n ► -- ----- --- -"' V __ 41.E
%..p�1 Crem atiorn tAcL I L e r 2.0,i Q Lik A rLD N.bLis- , N'y ti A0LA
.14 Date ( Place Removed _
' Removal i 1 and/or Held
and/or j"rurdress
-- - — - _
i s Hold
-- - ,
Date {Point of
P
[J Transportation [Shipment
„;�, by Common Destination
:; Carrier
Disinterment Date TCemetery Address _
< i []Reirrterment Date l Cemetery Address - --_
a.i Permit issued to TRepistration Ml.►rrber
Name of Funeral Home !� 1 . ( c�
�_: Address
-_ __- :.�,nf,�r��. Eater ��trx,�arl ,�.�f�C-_— -- �. i ! 3G ------_
1! Laky . Q SA. , Ck u.E.CJ sbur,J , N e Y+rir L 1 -sl U
Name of Funeral Firm Making Disposition or to Whom - w_�
Remains are Shipped, if Other than Above
Address
Permission le hereby granted to dispose of the human rem ins d earth ab s Indicated-
' Date Issued 01 Registrar d vital Statistics , _
. signature)
....------
a District Number tS-C SS--- Place /ll ti OT c/al ielr b(J/+y/am
• ? I certify that the remains of the decedent identified above were disposed din accordance with this permit on:
s'i
t`rti Date of Disposition I-tilt Placa of Disposition f i:u lik.-i er'ri1rc terivs�
- -- - Nr#rssa►
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�,. �']� _ num.,/ f9raus"fU�!fBbJ
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Name of Sexton or Pars •i1= charge of remises t hcos•�rr r - N�rfi -
0
lease pr�r.�
Signature Title LQ � __
(over;
DOH-1555 (0Zr2004)
utut iv !G LLD.uop baker --Lit-ieral Horn . ), 518 -rei 0044 p.2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
, ...
. Name Frst • Middle Last J
--7--„,
f ek
L e cA-h ( 1 . r—
.--- 3J-nner— :
-,.. Date of Death___' ! Age if Veteran of J.S.Armed Forces,
f•:. . 1 - 74 '--- War or Dates —
[14' Piece of Death . - — Institut° or
1*..44.,;(r6v_\3tv-v4hatit..- -So\-Nr-IstxL,LI•Li
p Manner of Death L.jr7 Natural Cause rj Accident El Homicide Ej Suicide r )6 Undeterminedj ni Fending
'C Im ircumstances ' estigation 1— —
ILI Medical Certifier Name -- . Title 1
\orn Vsi a nt r( ) oo-_,,_or> 1
Address
-- ' 8C4.0) fci Nhy--t-h CY i
ec.14- NY
g,.
1-• •
r , Dead" rtificate. Filed -r- . District Number -- I Register Number
'.• . , Tows - -.>cAnc150,,..ir 6% .s--- I
,
Date-T-
A ax\ q ol 'a '
efe ererriatoryf-.")7.,
AC....' \i‘i 1 c‘ :),
' P -
- .
DEseombrnent Address
(titCremation a ut...c--)A-er--- R.c.1. Q LAA...Q...51s buf,Li, )•.1'°.) I,a:1,044
0 ,
Date 1 Place Removed
z R ri Removal L. j and/or Held,---,and/or I Address
,...i Hold i
ta
0 ' Date —71. Pint of
ai 0 T,ansporiation I Shipment
a by Common Destination
'-• , Carrier i ---i'::•!, Disintermen 'Cemetery _t Date Address
----J _.......
Data Cemetery Address
,
LiReinte-inent -
. . ,
Permit Issued to ' Registration Nurrber
Narre of Funeral Home Ho.y riaf ci --0. ecij:.er 1.--1:4104-a_i ;"1---12- , C i SO
: Address
..i:.:
L
- —
1 Nine of Funeral Firm Making DispositiOn or to Whom
'1— Retrains are Shipped, li Other than Above
rtr Address
r
-... Permission is hereby granted to dispose of the human rem iris d scribed ab s indicated. -.
s-E':
.-.... Date issued / LE 020 j a-) Registrar of Vital Statistics 1So-9r:store)
___--,
,.
,:ii: District Number ,..5--g',sm— Place /e-/4.4,--, c_p j,
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ta Date of Disposition Place of Disposition
2 (address)
LIJ 1
4 I
CC (section) (lot flume ) grave lic:r.)ber)
10 Name of Sexton or Rersor ir, charge of Premises
m (please print)
Sicnature Title
(over;
DOH-1555 (02f20041.)