Stowell, Irwin NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name Fi t Middle Last Sex
Date of DeathAge If Veteran of U.S. Armed Forces,
//7// /V erj War or Dates /fs--;,5,
1- Place of Death Hospital, Institution or
Lti own or Village 67i''7S/ Z/, /6t7 ,.57. o6/��s
Street Address Alieie /44(
0 er of Death rk 5 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
tti Circumstances Investigation
W Medical Certifier Name Title
Address
/lJ O f/y-gm I7- 6/'r, �'4 // Aa 88/
,-.th Certificate Filed District Number Register N
>c Town or Village �/ / elf ,5-60 `-JQ
■Burial Date ///�� �� Cem ry or Crem
rCrem atory
, MC ��L C474 4/3/❑Entombment Address
[ remation av(t? 2S'S,r//) ,/(/ 42 gO5/
Date Place Removed
Z Removal and/or Held
2 I—Iand/or
h,;; Address
in
0 Date Point of
05 0 Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
iKiig Name of Funeral Home .0429—/ '� A/e,/ / ,/? -;P�L"% ,„(:_-- 66W,
Address 5C ( 4/9A2 / / �k 1 G
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
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W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /// ./giy Registrar of Vital Statistics lijcLuriN.z, \AL.A.)\-c.eict
(signature)
District Number 360 j Place 6/4'-s // / '7' � io/
I certify that the remains(of the decedent identified above were disposed of in acc rdance with this permit on:
ILI I , £ _Date of Disposition (IAA Place of Disposition ter ,,.
2 (address)
W
tfl
CC (section) i, (lot number) (grave number)
0ta Name of Sexton or Perso 'n Charge of Premises a"�'I>�. 3t'
Z r (please print)
Signature Title CktiLifIlittm
(over)
DOH-1555 (02/2004)