Stegen Sr, Norman -11
NEW YORK STATE DEPARTMENT OF HEALTH �Z 1
Vital Records Section Burial - Transit Permit
f:> Name First C� Last Sex
/VO2.Mk�.)I 1° Jr c�..) S/� 1/61- --
Date of Deat j Age of U.S. Armed Forc ,
> ?//7 J3 II a Dates
.,.., - of Death _ � �
al, oFl
.,.:dil, own or Village gt,6,J s ,- S 'Erectl 1'Erect Address -6-A S /-a2LS
S Manner of DeathvNatural Cause n Accident n Homicide n Suicide n Undetermined ri Pending
lAil
/ Circumstances Investigation
419 Medical Certifier Name Title
i
>. Address
A. ath Certificate Filed { District Nu j Regi er
Ci own or Village u-Letu S Fo _,
,---t Date i Cemetery Crematory
I I Burial 7 jab //..S—
Address i" Ui mil"`,
:Et: Cremation Date L 0 ig-X&� �- `'� tie b'iUS Q up, /U �.
❑Removal Place Removed �
and/or and/or Reid
1- Hold Address
I
0 ! Date - -wint of
N fl Transportation
j Shipment
a by Common Destination
Carrier
:::: n Disinterment Date Cemetery Address
<.: ❑Renterment j Date Cemetery Address
Permit Issued to ` Registration Number
>< Name of Funeral Home EaRer F era lame_ 1 at
i 30
El Address '
ll La:f y C.(e a , bit nsbt,:c.rcj; itiery LIOc){- lceoy
R Name of Funeral Firm Making Disposition or to Whom
.= Remains are Ship
ped,piled, If Other than Above
44 Address
a
Permission is hereby granted to dispose of the huma remain •escribed above as in•'cated
Date Issued �j7l�j/ (S Registrar of Vital Statistics /' ,' /,• _
// (sit ature)
tg District Number. a,O r Place ` _Z.da //; ,
I certify that the remains of the decedent identified above were disposed of in accordance w this permit on:
f-
EDate of Disposition 7/2_2/l5 Place of Disposition
2 (address)
CA
CC (section)
Z Name of Sexton or Person in Charge of Premises 1 (lot number) (grave number)
(AC. Ste
ZSignature (please print) V m
______._A____LTitle ( 1407)
(over)
DOH-1555 (9/98)