Stowell, Gene Tt 2`c7
NEW YORK STATE DEPARTMENT OF HEALT Burial - Transit Permit
Vital Records Section
Name First st Sex
C�en�
- S _e_i
Date of Death I Age I If Veteran of U.S.Armed Forces,
i :: UL-1 aS mot M i qo , War or Dates J q1 q q - / LJ
e of Death `r 1
Cit Ca UXAS' Ia.\ l S 1tAdd G Dort 5+
.n Manner of Deathj Natural Cause (�Accident [�rlomicide Suicide Undetermined Pending
1� Circumstances Investigation
tjj Medical Certifier Name Title
M I CA& �u,i LoA 1 PI
Address `(4)
Care d Qom. bt( f y mil t 2 c O
-ii .
D h Certificate Filed (`` District Number _ register Number ,
City, -CI t� v c k.l S �OJ) 0
> (Burial Dat
e Cemetery or Crematory
❑EntombrnentI � t ,� �!.,.„.„,ZEICremation ss U A, i ` " 12
Date Place Removed
0 ` Removal and/or Held
2 I and/or I Address
Hold
Date Point of
55.E Transportation Shipment
5 by Common Destination
Carrier _
:.0 Disinterment I Date Cemetery Address
n Reinterment Date I Cemetery Address
""' Permit Issued to i-� Registration Number
Name of Funeral Home 1 .�'�eX t-L;1L{t \ npf�l . CT)t 0.
Address �.
1k L.c.€c� it_ S-�- Lu ,- S\ � 1 / Ky 1Z Ct-1
Name of Funeral Firm Making Disposition or to Whom
14. Remains are Shipped, If Other than Above
Address
CL
IL1,
Eli
Permission is hereby granted to dispose of the human remains described above icated.
Date Issued `i ( 1 ( 11 Registrar of Vital Statistics
(signature)
<`' District Number' h U/ Place 6 r Fc, 1 ) S)N y
I certify that the remains of the decedent identified above were disposed of in accordance
with this permit on:
Ill Date of Disposition t(io Lq Place of Dispositionill '�iru Vb`r' (� os,-.-
(address)
ir (section) i (lot number) - (grave number)
Name of Sexton or Person in Charge of Premises /X i . t-4I -
tease prin
Signature Title (OM'
(over)
DOH-1555 (02/2004)