Clevenger, Beatrice NEW YORK STATE DEPARTMENT of HEAii.TH
Vital Records Section Burial - Transit Permit
` Name First )CQ-- Middle I 1 Last /i�e U� Sex r
vecor>ry 4 Date of Death Age I/fvVeteran of U.S.Armed Forces,
z13O1/(o �v War or Dates
{ Place of th ,,,.,,{{ Hasp" ns" or
City Village F#, ECLO{�' Street a �� LC[i��( l �,( ��J
Manner of Deatt)Fjjural Cause Q Accident Homicide Suicide Undetermined Q Pending
' "L Circumstances Investigation
Medical Certifier Name Title
/\/CCUX a. i 016) ut,_____9_1_______ki4 )
•
Address /00 all L & G C.S2.1Lo Fa , i.),•4 I.Z sty I
Dea icate Filed District Number Regist umber
City,Town Village r�. �Oxc, � 1��
Date Cemetery tr Crematory
0 Burial 12` SO I l(,.0 v i nv v
Address:::036.. QC__j Q u &: emotion � 1 1Q./ 1`Z1G
Date Place Removed
0 Removal and/or Held
and/or Address
651 Hold
Date I Point of
1 0 Transportation f Shipment
a by Common Destination
Carrier .
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
J. Permit Issued to Registration Number
f. Name of Funeral Home i 6a i7,1 Fw ecu-, Home- 01130
0
Address 1, LacCUIRALC 3f. , bCL eDSk r 1Je.0 t-vrk- /aRYI
-- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
„
'.-: Permission is h granted to dispose of the hums s descri r o 14indicated.
- ' Date Issued 3 �,6 Registrar of Vital Statistics , 1 r 0
5F� Place I 5 ' i-t
District Number���/ � """ � V '�"
I certify that the remains of the decedent identified abovewere disposed of in accordance with this permit on:
ti Date of Disposition I/3 I f? Place of Disposition NIL k '_ .
+„ (address)
!A
> (section) (lot rum (grave number)
Name of Sexton or Person in Charge of remisesCI 6
d 1 11
g (please print)
t! Signature a' Title r .tttali_
(over)
DOH-1555 (9/98)