Cowles, Ida NEW YORKTATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
115 Name First .. 'A+� Middle J ' Last /1 ie S Sex F.
=L-
a Date of Death t , Ia�'ad�3 4 Age if Veteran of U.S. Armed Forces,
_; War or Dates _
P e of Death � a Hesafett nstitutio r I l_^ (\ i4
City rerVi lac,�e CCa`'`�' ee , r tx N
t'"'" Manner of Deatty ' atural Cause El Accident El Homicide Suicide 0 Undetermined D Pending
ii5�'�� Circumstances investigation
Au Medical Certifier Name c,itZ iv_ L6 Jo` Title
J
! Address / /0 tdanit.en T i J 6te,azFa , N/ to z 1
R th Certificate Filed District Number Register ber
4 ity. r . C-7 , salts - 60' � '
' Date 5 *015
emetery C 'jam v�
►i : real Address 0
(Laker
l/j,1 ) ujuiv3+ (/( Li,
m 0 go4
': ['Cremation
Date _ Place Removed-
. t❑Removal , and/or Held
E= and/or Address
Hold
Date Point of
FA❑Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
f : Permit Issued to ) Registration Number
>`>t Name of Funeral Home np . i2.1 Z.\ �. R pr t ) i PJ �143 r,AN e: i 01/ 30
y
~:_ Address /
.,
--- 0 Ua--->a.c.IS e r Ay. 1 2..P-o it
ill Name of Funeral F m Making Disposition or to Whom V r
F. Remains are Shipped, If Other than Above
Address
i ,
r.:; Permission is hereby granted to dispose of the human remains described above as indicated.
- Date Issued Li/30 1/3 Registrar of Vital Statistics tij CA.)�'N.R.-
ili (signature)
12
al District Numbei;.6/ Place ([.1/�''zc7ii/�..f /�J1`
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f.
#tl Date of Disposition 5/3/1 3 Place of Disposition Pine View Cemetery
2 (address)
W Ondawa 11 C 3
tc (section) (lot number) (grave number)
0 Name of on or Person i• harge of Premises Connie. L. Goedert
2 (please print)
1 I Signatur I'e-� i Trtle Superintendent
- (over)
DOH-1555 (9/98)