Stewart, Frances NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sql
/=rc c rr c ..s C. Srr A
Date of Deat 13.
Age If Veteran of U.S. Arme Forces,
G 9 �� War or Dates
l Place of Death /� Hospital, Institutior� ,e ��
Z City, Town or Village (� /(�F�r /,4LLc /./f Street Address `7 &4Ys �,,A , gi)sP.. i o9 6.
ig Manner of Death Natural Cause Accident ❑Homicide E Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Ati Medical Certifier Name Title
o ` 13 e.111, ,R 0 s--iz 0/49
giiii Address
/o, ,4 �`7--1. Ctrs—ems 4 LL r a- r
iiii Death Certificate Filed District Num er Regi§ter Number
City, Town or Village (J(ivs-1,4 Ls,/'V 6e / 4<77
Date Cemetery or Crematory
CD Burial q��l/ r/ ne.-4,11 !�.,r c� r-0191/d0l' •
Address
LCremation b
FDate Place Removed Y
. ❑Removal and/or Held
••, and/or Address
gHold
o Date Point of
iii❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
'' 3 Permit Issued to ,—. Regjtrj�o n Number
iiM Name of Funeral Homey ( Ls�� i� �/-ti�n�y L � �1�'t �nC`i
::; Address I-( (d/1 7,/x/4) 6.-- �r, , )1
L;; Name of Funeral Firm Making Disposition or to Whom
*' Remains are Shipped, If Other than Above
Address
CC
iiiiii Permission is hereby granted to dispose of the human remains de cribed above as in ' to
Oii Date Issued ! / 7fc Registrar of Vital Statistics /� , d d`
si na re
District Numbeav ( Place O -S- N 6-4-5 f /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition —01..` Place of Disposition/ '///,g �lc/ ,f ,6/►//1 /( / /'t
„ (address)
iU
NJ
CC PCt (grave number)
Name of Sexto or Person in Charge of Premises t4/j lC P �►�1 "r/r�/y
z (please print) .�
Signature Titleeir,,6-44/9k5fiy / ;/
DOH-1555 (10/89) p. 1 of 2 VS-61