Bowman, Elsie NEW YORK STATE DEPARTMENT OF HEALTH 4 - �r G Z
Vital Records Section Burial - Transit Permit
«= Name First Middle
(';�>� E ISj e Last jjam�,,,, � Sex
Date of Death `'��, j F
1 � Age I If Veteran of U.S. Armed Forces,
1 J 15 '33 War or Dates n I
'" Place of Death ! Hospital, Institution or N '
>. )Town or Village GI,Q21)�S >ra1\ I Street Address Pi h tis K u-' S`Ci
-„; Manner of Death Natural Cause E Accident Q Homicide n Suicide n Undetermined nding
Medical Certifier Name Circumstances Investigation
- De ,j r Title
l�
�
Address i
Death Certificate Filed , e 14 4 6 a- • c N )? L
_ � \�� District Number i -egister Number }
fiii
Town or Village 5r0 O' L/2-'` f
i Date p I emetery or Crematory
:<: (J Burial I Address0O / I g.C�j� DOY�.Sbu r� M ) O
! D
Cremation i i'n \ I i e l � ' f
Z Date �J Place Remo/ed
-1 Removal
-- and/or __-- ' and/or -!Lid
Hold Address -- --- --
3+ Date -- —.iirt of
a 0 Transportation i
i Shipment
a by Common Destination
:i Carrier
- i ;Disinterment Date; ; Cemetery Address
: Date
::: I I Reinterment Cemetery Address
<> Permit Issued to 2 _
= Name of Funeral Home .UC(tt✓r Funeral 'lame_ 1 Registration Number
Address f• GI13
LafCLy
:'l-tc a , cif cnOaLrc.j ; 2 Lk:-Al- ,_AY/
Name of Funeral Firm Making Disposition or to Whom
I44 Remains are Shipped, If Other than Above
Address
Permission is herebygranted to dispose of the human remains described above as indicated.
Date Issued . )2 el /5 Registrar of Vital Statistics
_4 'v°�l/1ti3L ‘..A.)_,\-,CefOr
nc
(signature)
i;if«. District Number E 60( Place (-,C j o, \S AI y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
14
ILI
Date of Disposition WOK- Place of Disposition fr2.4V,w.,1 Cr vN.
tu (address)
112
fl Name of Sexton or Person in Charge of Premises‘._.., (section] Ic3c n tuber}
,t](grave number)
-z �� r I L- Sln"" I
(please print)
Signature Title fakj11#1
(over)
DOH-1555 (9/98)