Stapley, Hester NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name Fir
f ete
yti i Middle Last Sex
fries A, ci 7" t--
Date of Death Age If Veteran of U.S.Arm d Forces,
11-16- 92 . 7 7 War or Dates /t40
z Place eath Hospital, Institutio r
uj City,(TovOr Village Ly;,„ZdA/04,_) Street Address 0,4cie, AGite X/eioe____)
..1.-1- Manner of Death i 3 Natural Cause D Accident [:1 Homicide El Suicide 0 Und ermined n Pending
Circumstances'—' Investigation
,u) Medical Certifier Name ../ Title
Addre s /
a4,/),
Deat ' 'Cate Filed p:, , , AA istrict Number Register Number
City, own. Village elizAh e y-ktki.0,c)
rcitl
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Date C ry or Crematory
CI Burial /77- /e *-1.,. C/0/10/47/19.(.
Address (,)
Cremation
/ veeii_4 ior 1y- Ai/
z Date Place Removed
O 0 Removal and/or Held
and/or Hold
Address
U)
Date Point of
u) Ei Transportation by
_ Shipment
c) Common Carrier
besiination
Date Cemetery Address
O Disinterment
Date Cemetery Address
O Reinterment
Permit Issued to Registration Number
7
' - Name of Funeral Firm elaj///p /, / //r- 744/76,/e/j/lope_
1 6
Address ) /
..f'420e)/11 ki,et /fi/ /Z 76)
)- Name of Funeral Firm Making Disposition or to Whom
.2._
Remains are Shipped, If Other than Above
:CC Address
ui
a.
Permission is reb granted to dispose of the human remains, described above as indicated.
Date Issued Registrar of Vital Statistics ..-6,-/-7..-0.-:-(c..-41/1--- (
(signaVe)
/
District Number /13-'1- Place (//2.-n4et'lfel-C.if/t/ .//,
/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition -tis-5?-3 Place of Disposition ,<--- 1,1P41 /? "L/'/11
ta
E (address)
La
cn
CC (section) (lot number) (grave number)
fp• Name of Sexton or erson in Charge of Premises ,e7Pil/5 2/CB ,,,4 /52 7/-e7 9 I/
Z (please print) )
u..I
Signaturef- ..---of Title
D 0 H-1 5 5 5 (10/89) p. 1 of 2 VS-61