Edna Annabell Vandeusen36. LOCATION--CITYITOWN, STATE
37, DATE (Mo, Day, Yr) 34, CEMETERY/CREMATORY--NAME
•
32. BURIAL,CREMATION '
HE AL OTHER(SPecMy) 33, ADOREs30F FACILITY
C L
37. NAME OF FACILITY �
36. FUNERAL DIHECTOH sIGNATURE ,L
• RAL H� 4
/ THIS BURIAL PERMIT MUST ACCOMPANY REMAINS TO DESTINATION
ACERTIFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE LAWS OF THE STATE OF
WASHINGTON, PERMISSION IS HEREBY GIVEN TO DISPOSE OF THE BODY AS STATED ABOVE.
REGISTRAR ADDRESS
DATE SIGNED (Mo., Day, Year)
REGISTRAR SIGNATURE '-'R 99 ga
CEMETERY OR CREMATORY SHALL FILL OUT SPACE BELOW
in
Body was (MO., DAY, YEAR) (CEMETERY OR CREMATORY)
(BURIED OR CREMATED) on
Signature X
Place (SEXTON OR PERSON IN CHARGE)
See other side
orsed by the sexton where interment is made (or by the funeral director where there is no sexton).
This permit must be end
Return within 10 days to the registrar of the district in which the cemetery Is located.
can 21f1
FOR INSTRUCTIONS SEE BACK AND HANDBOOK A
1!I 11 Ir 1
1 If I f 5 1
1
ydrsSin;Im See prprtunl r{
Health 146-- '
STATE FILE NUMBER
PERMIT
BURIAL -TRANSIT
• LOCAL FILE NUMBER
2. SIX (M /F)
3. DEATH DATE (Mo, Dey, Y()
1. NAME Fleet
_
Lcat
Middle F'1ALE
r2�.DE1�L V• � ""L.1AM �.ft�
�V � EN D. WAS DECEDENT
1 31198
EVER 10. COUNTY OF DEATH
ldJ t1
BIRTH• 6. UNDER 7 YEAR
S. BIRTHPLACE IN U.S. ARMED FORCES?
8. UNDER 1 DAY 7. BIRTHDATE (Mo, Day, Y() (City Stale or Foreign Country) (yoy No) , NG
4. AGE LAST
DAY (Yre) MOS DAYS
I HOURS MINS O 02 CLAIRE IL 13. SMOKING IN LAST
O 16 YEARS? (Yes INo)
ADDRESS OR INSTITUTION NAM
95
TOWN OR LOCATION OF DEATH
12. PLACE OF DFATH—�I BOX FOR PLACE THEN GIVE
3. 0 EMEND. RMNILI PTH 40 HOSP. 5 NIA NOME 6❑OTN81 PLACE.NO
11• CRY,
•7.1+�A i LE
SEATTLE
1U1.❑HOME 201HTRAHSPORT
L"r L' S•1• V IKEwr 17, DECEDENTS EDUCATION
16. SOCIAL SECURITY NO. (SPwity wty NDheh Drade completed)
14. MARITAL STATUO— Mrrled,
16. SURVIVING SPOUSE (11 %06, give maiden Warne) Ep(neMN,/Becpldery (o -12i CaneDe (1,4 or 6+)
Never Muried, Widowed,
Divorced (SpecitY)
.
505-30-9297 12
WIC
36. LOCATION--CITYITOWN, STATE
37, DATE (Mo, Day, Yr) 34, CEMETERY/CREMATORY--NAME
•
32. BURIAL,CREMATION '
HE AL OTHER(SPecMy) 33, ADOREs30F FACILITY
C L
37. NAME OF FACILITY �
36. FUNERAL DIHECTOH sIGNATURE ,L
• RAL H� 4
/ THIS BURIAL PERMIT MUST ACCOMPANY REMAINS TO DESTINATION
ACERTIFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE LAWS OF THE STATE OF
WASHINGTON, PERMISSION IS HEREBY GIVEN TO DISPOSE OF THE BODY AS STATED ABOVE.
REGISTRAR ADDRESS
DATE SIGNED (Mo., Day, Year)
REGISTRAR SIGNATURE '-'R 99 ga
CEMETERY OR CREMATORY SHALL FILL OUT SPACE BELOW
in
Body was (MO., DAY, YEAR) (CEMETERY OR CREMATORY)
(BURIED OR CREMATED) on
Signature X
Place (SEXTON OR PERSON IN CHARGE)
See other side
orsed by the sexton where interment is made (or by the funeral director where there is no sexton).
This permit must be end
Return within 10 days to the registrar of the district in which the cemetery Is located.
can 21f1
FOR INSTRUCTIONS SEE BACK AND HANDBOOK A