Baker, Jacob Michael NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Jacob Michael Baker Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/20/2022 42 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Rome Street Address Rome Memorial Hospital Inc
p Manner of Death Natural Cause nAccident E Homicide Suicide riUndetermined Pending
W
0 Circumstances Investigation
WW Medical Certifier Name Title
CI
Andrew Bushnell MD
Address
1500 N James St,Rome,New York 13440
Death Certificate Filed City Of Rome District Number Register Number
City,Town or Village 3201 345
Burial Date Cemetery,Crematory or Facility Name
07/27/2022 Pine View Crematory
Entombment Address
MCremation Queensbury Town,New York
❑Donation
O Date Place Removed
R L_Iemoval
and/or and/or Held
N
Hold Address
0
EL Date Point of
U) Transportation
Lp by Common Shipment
Carrier Destination
EDisinterment Date Cemetery Address
Date Cemetery Address
III Reinterment
Permit Issued to
Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
E. Remains are Shipped,If Other than Above
Address
lY
W
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/25/2022 Registrar of Vital Statistics lean Isom Grande(ECectronica1fySigned)
(signature)
District Number 3201 Place City Of Rome
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
VW7 LrG>Date of Disposition �,,y�Place of Disposition I hL ry
(address)
W
w (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises ��(rn(��' Sc
i(vS
Z (please print)
Signature / �� Title C.,Cam»O6
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
1 1 Human remains of delivered on , 20
1
1 .
Pine View Cemetery Representing the funeral home named on burial permit
t Official Funeral Directors Reg.or License#
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