Bruggemann, Lester SIAItOh-VEHMONT
0 4BURIAL-TRANSIT PERMIT Permit No
DECEASED—NAME FIRST MIDDLEr[ LAST SE DATE OF DEATH/// (Month,Day,Year)
1 Lester U
RACE—(White,Black, AGE LAST BIRTH- UNDER 7 11YEEARR� E X3 UNDER 1 DAY DATE OF BIRTH 3 COUNTY OF DEATH
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American Indian, e�7 y DAY(Years) MOS. DAYS HOURS MIN. (Month,Day,Year)
4 ETC.(Specify) Iliii i i_A 5A 69 5B 5C 6 .} ry 7A Add t (�/�
CITY,TOWN OF DEATH HOSPITAL OR OTHER INSTITUTION(If not in either, 1 L 4Pf1Q3PITAL or INSTITUTIC
7G P g:or Sneet andNu. ber) (+ ❑ Inpat. ❑ ER ❑ 0
7B N 1d Jebury y ny+1{ Br M d i c l .,4erltC�r 7D
PERMISSION REQUESTED FOR: ��
LK BURIAL ❑ CREMATION ❑ TEMPORARY STORAGE
8. (Complete Item 12 below)
PLACE OF DISPOSITION(Cemetery or Crematory) (CITY OR TOWN) (STATE)
9. eAlEV,eLJ G,lz,V,Vs ,/1.5 /V y
NAME OF FUNERAL DIRECTOR BUSINESS ADDRESS ,
0 10. CSicn/E e. FA-T z< 11 D`-DO4.FL is(i Ay •✓T
IF TEMPORARY PLACE OF (Name of vault) (CITY OR TOWN) (STATE)
STORAGE,FILL STORAGE
IN THIS SECTION:
12. 12A. 12B. 12C.
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PERMISSION IS HEREBY GRANTED TO REMOVE AND DISPOSE OF THE BODY IDENTIFIED ABOVE:
Signature of clerk or deputy CITY OR TOWN DATE
13. , ,..e... ie c:=.7.-. &-‘) P-11) '114 64 •-' ,
15.
CEMETERY OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW:
BODY WAS. DATE NAME OF CEMETERY OR G14EMAi9FUF SECTION LOT NO.
❑ BURIED 17.6—/B—A5 18. 1---L N.)e 16 1 C' W ,,Q=',ery .,1�.,- Li 19. ✓ /J 20. 6
LOCATION (CITY OR TOWN) (STATE) SIGNATURE OF SEXTON OR
❑ CREMATED OTHER PERSON IN CHARGE
❑ STORED
erMc_uSoleua11
16. 21. L.) `,e N S V V 22. 1,732A ✓ I4 I A A