Bowman, Eleanor NEW YORK STATE DEPARTMENT OF HEALTH ((y
Vital Records Section Burial - Transit Permit
= Name First .. Last
t Middle . Sex
—Firs .
- Avg t.� �.� rn AN _
Date of Death i Age If Veteran of U.S. Armed Forces.
O. I /9 /ao 15 `&9- War or Dates
Place of Death — —
' Hospital, Institution or 1-
tit-
City Town or Village C�vr✓E t--5(3vQ ti Street Address q s(o She ZovAc 1 4°(
Manner of Death Natural Cause C Accident fl Homicide i l Suicide fl Undetermined 1 Pending 1
titj
Circumstances Investigation 1
fir Medical Certifier Name Title --'
Address _�
Ito I C_A h Q( C i
Death Certificate Filed ;
istnct Number : Register Number
Grty, Town er-V4618ga L NS Q5u Q't_ S 5 3 (
Date _ Cemetery or Crematory 1
Burial 3. l a b 1 oZC�)5 s'
1 C\3 ��E AJ i d��
Address —
Cremation! (j v p 1L e CZ-o ceA Q
Date
Z Removal Place Removed _--
ftand/or and/or +-Held
_ ddress� Hold
Date — {
E Transportation Shipment
p by Common ; Destinatior.
Carrier
- -------- --
: ! !Disinterment Date
Cemetery Address
Date ___
n Reinterment Cemetery Address
Permit Issued to -- _
Name of Funeral Home' /a�_ r/a Id 9� /`..czA e1 / f(- (l Registration Number
i Address l^ — —— --- ----._._
l I_CC I a i.- (,CC.- .��f. f U,t(, -<_1.;")S ch(-i C_ �t 1 Cfu'�j- /. F J�)
------ --------
Lei
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
a- Address
Permission is hereby granted to dispose of the human ins d b ab e s indicated.
Date Issueo ,)—c o- (`--) Registrar of Vital Statistics
(signature) -- —'
District Number S S1 Place __ — --�I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ElDate of Disposition 2.(7-811S Place of Disposition Zliii--i C1. tdr
(address)
L
ICC
(section) (lot number
g Name of Sexton or Person in Charge or Premises r (grave number)
12
Signature4:______141 (please print;
Title • 611
over)
DOH 1555 (9/981