Stevenson, James c/° 7
NEW YORK STATE DEPARTMENT OF HEALTH . - t
Vital Records Section Burial - Transit Permit
Name First— Middle La � Sex,
" ' Date of Death 1 1 ' Age If Veteran of U.S. Armed Forces, / f
/o p* 3 7( o War or Dates /V/d44
City,TacTown Village Q.{eeii-5kft,(44Street Address �Z J--�L�Ct C5►�ld ��J
Manner et Deatt.Natural Cause Q Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name P./
Title AL)
0 f t2 i d_ &La`/7 CIA_
•h: Address a
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l C-(�'...lj� �C.� l Gil T�Z_ Cc �D U/S f
Deaf u date Filed District Number 1 Register N r
• $. City,re). Village QUt0 ?Sbl tR..� 5-7
Date 1 Cemetery oCCremat
::` ❑Banal Apj//'/,j AI V /'VA) l reiY4t
Address
::.:
::? Cremation Goo ki r u
VJA eeri3SurtiAI y !28OLj
Date Place Removed
g 0 Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
5 by Common Destination
Carrier
'`El Disinterment Date Cemetery Address
0 Renterment Date Cemetery Address
x Permit Issued to
s` /� /' r �}, key Registration Number
Name of Funeral Home Fc we�a/ force 01130
, °` Address
Ii LQ a y `e (31-. , &bccensio ry i New York iaeey
F
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Name of Funeral Firm Making Disposition or to Whom
x. Remains are Shipped, If Other than Above
• Address
iC
' Permission is hereby granted to dispose of the human reirains described ab as indicated.
Date Issued /0.-11- p. Registrar of Vital Statistics ,c,QJ _
(signature)
j.
District Number 5ips-/ Place ,,., v�
` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f$
r,
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Date of Disposition 10115113 Place of Disposition
(address)
F (section) If A ,(lot numb (grave number)
Name of Sexton or Person in ge of Premises L Al „,sit{•
Z► (please print)
t. Signature 4. Title etnetittliet
(over)
DOH-1555 (9/98)