Bowman, Maverick NEW YORK STATE DEPARTMENT OF HEALTH # bZr
Vital Records Section ys. Burial - Transit Permit
Name First Middle Last Sex
Maverick 74ssell Insley Bowman Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/26/2018 15 yrs. War or Dates No
I-- Place of Death Town of Hospital, Institution or
Z City, Town or Village Putnam Station Street Address 1 1 1 0 County Rte. 2
W▪ Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Michael Sikirica M.D.
Address 12208
Albany Medical Center, 43 New Scotland Ave. , Albany, NY
Death Certificate Filed Town of District Number Register Number
City, Town or Village Putnam Station 5763 2
OBurial Date Cemetery or Crematory
8/2/2018 Pine View Crematory
i ; ❑Entombment Address
®Cremation Queensbury, New York
Date . Place Removed
❑Removal and/or Held
and/or
Address
U)
Hold
O Date Point of
❑Transportation _ _ Shipment
6 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox &,','Regan Funeral Home 01 821
>» Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
I
Permission is hereby granted to dispose of the human re " s described} above as indicated.
Date Issued 7/2 9/2 018 Registrar of Vital Statistics O-1,.9
(signatur
R. District Number 5763 Place Town of Putnam Station
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILE Date of Disposition 9/2+I$ Place of Disposition fm Li ,r..7iw-.,
12 (address)
L
Cc (section) (gig t number (grave number)
ci Name of Sexton or Person in Charge of Premises �tr\ Z'-
(p/e a print)
Signature Title filin'1iT(>r .
(over)
DOH-1555 (02/2004)