Bowen, Gary 1 D7-1 1 ; 1 2:4aphis; . 51 a 644 247e, ;
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
4.
:: Name First Middle Last I Sex
$::: Gary D. Bowen 1 Male
. gof.,: Date of Death Age If Veteran of U.S. Armed Forces,
:.: November 4,2011 69 War or Dates
j_ Place of Death Hospital,institution or
;Z City,Town or Village Bolton Landing Street Address 11 Park Rite Road
p Manner of Death NJ Natural Cause Li Accident 0 Homicide Suicide Undetermined 17 1---"Pending
W CircumstancesInvestigation
'tu Medical Certifier Name Title
p. Robert Sponzo,MD
;; Address
r . Glens Falls,NY
Y-: Death Certificate Filed I District Number Register Number
:. City,Town or Village Town of Bolton,NY 5 65 0
E Burial T Date Cemetery or Crematory
EnUombment November 8, 2011 , Pine View Cemetery
Address
❑Cremation i Quaker Road,Queensbuy,NY 12804
Date I Place Removed
Z I Removal I and/or Held
C and/or Address
F' Hold
Li
I Date I Point of 1
Transportation ; Shipment
p by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
:iiiii Permit Issued to I Registration Number
Name of Funeral Home Singleton-Healy Funeral Home ' 01596
Address
s': 407 Bay Road,Qucensbury,NY 12804
g:; Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
6 Address
IX
Permission is hereby granted to dispose of the huma ins described above as indicated.
0 Date Issued I I- 7 �0a Registrar of Vital Statistics • ti4..c41
;.: (elQnature)
District Number 6 5 D Place Town of Bolton,NY
',
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 11 /8/1 1 place of Disposition Pine View Cemetery _
WW (address)
vt Mohican 4RF 1
a (section) (lot number) (grave number)
Qp Name of Sexton or Person i arge of Premises Michael Genes
Z - (pleas.print)
ISA I Signature -u'' Title Superi ntPndPnt
(over)
DOH-1555(0212004)