Bartholomew, Cassius _. REGISTRAR'S
FILE No.
TRANSIT COPY DEPARTMENT OF HEA STATE OF ARIZONA HEALTH SERVICES - VITAL RECORDS SECTION /
(THIS COPY MUST ACCOMPANY BURIAL—TRANSIT PERMIT (.
BODY TO FINAL DESTINATION)AMEOF B. MIDDLE C. LAST �'7�,,'
SEX AGE "ACE OR COLOR
NAMESA. IRST CASSIUS RANT T 101 A• White
DECEASED F1�L�L\CIS BARTROLOMEW 2. )tale 3• STATE
1 A. TOWN OR CITY
IDENTIFICATION DATE OF DEATH PLACE OF DEATH
OF May 19766.
Phoenix Mari co Pa Ar.
CAUSE MUST
2-O a
DECEASED OF MUST BE COMPLETED IF BODY IS SHIPPED OUT OF STATE, MOVED BY COMMERCIAL CARRIER, OR A DEATH FROM CERTAIN DISEASES)
DEATH
B. ST. ADDRESS C. CITY AND STATE
7. • • • ' -
- FUN ERAL HOME A. NAME
0 BURIAL 0 OTHER •hoen_� _- --•
MANNER (SPECIFY)9Mercer Mo uar & Cha•e1 1541 E. Thomas Rd. DATE SIGNED
ID CREMATION FUNERAL DIRE S IGNATURE 5/28/76
AND EA REMOVAL !�/ / • 11.
PLACE OF 0. Ai//•� C. CITY AND STATE
8. N ME B. STREET ADDRESS
DISPOSITION PLACE OF BURIAL OR Glens Falls, New York
OTHER DISPOSITION Potter Funeral Service
12.
13.IN ACCORDANCE WITH THE LAWS OF THIS STATE AND THE REGULATIONS OF THE.STATE DEPARTMENT. OF HEALTH PERTAINING TO DEATH CERTIFICATES
REGISTRARS S THE HANDLING OF DEAD HUMAN REMAINS, AUTHORIZATIONREG. DISTRICT
IS HEREBY GIVEN TO DISPOSE OF THIS BODY IN THE E MANNER
INDICATED.
SIGNED
ATE
AUTHORIZATION S SIG
REGISTRAR S SIGNATURE O/�n /� � 18• � �
FOR 1
t5 G� oL_/ C. CIT AN• STATE
DISPOSITION 4 A. NA S ADDRESS
/ CEMETE'oR •' _ /�,/,J� �" -LL"
BODY WAS: CREMAT�.RV A ni ( / / G i�--`�`-
050 BURIED 18. V �/ �/
DISPOSITION CEM TERY ANAGER-- S GNATU-
OF BODY []CREMATED DA E PPPPPF • SPO-I TION ��
(SPECIFY) fL
❑OTHER 19. / / �. 20.' �� - TITLE
1 A •F CE -EGISTRAR S SIGNATUR-
STATE 22 B.
REGISTRAR USE 21. 22 A.'
VS-7 REV. 7-74
DEMETER MGR.
OF HEALTHI TRANSIT
TICOCOP
Y IN 10 DAS XYS TOZO T VITAL RECORDS, P.O. BOX 3887