Cowles, Alexander C -27
NEW YORK STATE DEPARTMENT OF'HEALTH
Vital Records Section Burial - Transit Permit
Name Fir t Middle Last Sex
M-L�xe.^^ Ae_n C Cowesl 41.
ai Date of Death Age If Veteran of U.S. Armed Forces,
a / a‘,/ ,9, ok`r War or Dates
} Place of Death Hospital, Institution or_
';.:, 'Town or Village 6Zes -FK lis' Street Address 3 /'1.1-kA.l� 5--.
fanner of Death M Natural Cause El Accident ❑Homicide Suicide El Undetermined ❑Pending
0 Circumstances Investigation
tu Medical Certifier Name Title
0 NJ (34,tRs-tbrHAAAs&,,,` M'-
Address N y A
Certificate Filed - i District Number eiegister Number
i own or Village &Lis ,..N.li 1 5-6D 1
LBurial Date / Cem ry or Crematpy
a/QEntombment a6 � ao/7 in,v''e,-, e4—A-sr
Address
®Cremation A.c t4 s IJwT .) /J ro1.l
Date J Place Removed
g1=1Removal and/or Held
g and/Holdor Address
=
+ _
0 Date Point of
II ❑Transportation Shipment
ci by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to - , Registration Number
—
Name of Funeral Hom e-AS4A0 rc- ,v_rti( ,-,e, 1, 69 o'/-'/
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
ill
Permission is hereby granted to dispose of the human remains descri e ov as ated.
Date Issued /a /a.6 //7 Registrar of Vital Statistics J `Z..--
// � (signature)
District Number 5-(a l Place ---f-�c. (/ Nam,.., / r�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition (t/'L4/i 7 Place of Disposition 'r pi eL)141 (i�4,1
(address)
Ili
VI
CC (section) (lot number) (grave number)
ti Name of Sexton son i Charge of Premises Jt"- <(' h 6 44--31 4.1,+2
(please pant)
1 Signature Title C /C� /-o'!
(over)
DOH-1555 (02/2004)