Myers, Baker Mae Pe l D
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Baker Mae Myers Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 25,2022 Fetal War or Dates N/A
;; Place of Death Hospital, Institution or
gr City, Town or Village City of Syracuse Street Address Crouse Hospital
Manner of Death Undetermined Pending
Natural Cause Accident I 'Homicide Suicide
Circumstances Investigation
g Medical Certifier Name Title
g Richard Semeran MD
Address
Syracuse,NY
;' Death Certificate Filed District Number Register Number
City, Town or Village Onondaga County
Burial Date Cemetery or Crematory
❑Entombment July 28,2022 Pine View Cemetery
Address
❑Cremation Queensbury,NY
Date Place Removed
Z Removal and/or Held
0 and/or Address
H Hold
U)
0 Date Point of
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:;: Name of Funeral Home Farone & Son, Inc. Funeral Home 00570
Address
1500 Park Street Syracuse,NY 13208
gi, Name ofns Funeraare Firm Making Disposition or to Whom h �-(J2 �Y6 -NA. Oita(
�, Remains are Shipped, If Other than Above CJL.(J�
FE Address
-re l 1la Cuivv v'L WiCa. n I354l
,,- Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued r. L /^Z-Z- Registrar of Vital Statistics "YI1,
r' t (s turn)
District Number 3500 Place Cc Ann Qt" QnARUa3c\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
w Date of Disposition --k.Dc6Place of Disposition (t Cs)uckle,,R RD Cer�\--x1c 1V� 1� •4
co Abex k. ► a C.ss) I A
w
(sectio --) (lot number) (grave number)
0• Name of Sexton or Person in Charge of Pre . s �Mt1%G. dCc ic`-\"
I /�Z D 1 Title C (please print)
Signature `s. ,e u,,c� r i (.
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b)
012932
Receipt
;
Human remains of -~t ./ delivered(41 ' , 20 --
1
1Ati 1/1"-
PineVievti Cemetery"- Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
MYERS I:)
NAME Baker Mae Myers Age: 0 ,`
Lot Owner: Shawn Harris
Lot# Abenaki 9 C Grave# 1 A
Case: Infant Casket
Died: 7.2 5.2 2 Interred: 7.2 8.2 2
Funeral Home: Farone & Son Inc. FH
Syracuse NY
Cemetery:
Pine View