Vaughn, Stphen t . ,. # 2 3 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:: , Name First Middpf Last Sex
\S-4--e--.-pkr24,:.,/•-- Date of Deatni Age , If Vetetan ot U.S. Armed ForcAs,
.-:...,
14 -AT - I-3 _50 ; War or Dates ( CI I z_- 46
_
Place of Death i' Hospital, Instituti24,or
11 City. Town or Village .1eAr),SEIS , ' Street Address ( 1,(t') i---4 t Sp dal
Manner of Death 0 Natural Cause El Acciden E Homicide 0 Suicide ri Undetermined ' A Pending
. 4 Circumstances Investigation
Au Medical Certifier Name , jitie
m1L
vJ1
,,_
Death Certificate Fileq- i District Number , Register Nktmber
0,3-own or Village < 1,ef) I SOO) 1•-,-..e
Date jyritLee,ry or Crematory
Ei Burial - 001,, oTab )3 VI ELA
"L...._
Address
LACremationli ,\,
Date Pla e Removed
t r—1 Removal and/or Held
0 L-1
and/or Address
,....ii-: Hold
2. i Date
Point of
ta-d.El Transportation Shipment
0 by Common Destination
Carrier
' Date ---- CemTerye Address
Ei Disinterment
Date Cemetery Address
,
u Reinterment ,
Permit Issued to Registration Number
Name of Funeral Home --1-4-C---c 41/ Z. OW-.)1
.
•-: Address Loa ) ur /
k,
___A __ q )1gt-i(d
. ' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'14 Address
„.4.,
":..: Permission is h reby granted to dispose of the human r: ains d:scribed ab•ve as in i : •.
-•::, -
Date Issued 0 Registrar of Vital Statistics 4 1.7,,,,_,- 4.... _44 -
_....
0
(signa re)
• 11
,. .
. .District Number. Ze(),,Z. Place Ao....: 4(.. 4 -/-.. /./4 A
/
Thertify that the remains of the decedent identified above were disposed of in accordance with is permit on:
fi it f D Date
of 'Ll-I> Place of Disposition
ILI4 .Ut1") Creifrtkkom"
2 (address)
w
CR
CC (section) nunVer) (grave number)
0 Name of Sexton or Person in Charge of Premises .no - endit
0
Z (please print)
41 Signature lif L. . i.,..._ Title azaryrrolt_
DOH-1555 (10/89) p. 1 of 2 VS-61