Bothwell, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bothwell Male
Date of Death Age If Veteran of U.S. Armed Forces,
996
War or Dates
Place of Death Hospital, Institution or
City, Town orViIIageqaratoqa Sprincis Street Address
Manner of Death®Natural Cause Accident Homicide ❑Suicide 0 Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Susan
Address
Death Certificate Filed District Number Register Numhpr.
>' City, Town or Village91 _
Date Cemetery or Crematory
El Burial January 12 1996 Pine View Crematory
Address
Cremation
Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wi 11 i am J. Burke & Sons F n
Address
628 North Broadway, sarato a Springs, New york,
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hum rema describe Iabovv` as indicated.
Date Issued 1/12/9 6 Registrar of Vital Statist" s
lsgnature)Ij
District Number Place
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
Date of Disposition��L Place of Disposition z'01
(address)
g (section) -P J"I
MAU)
(grave number)
0� Name of Sexto or Perso n Charge of Premises l✓
(please print) /�
Signature Title Alt/ �15i r
DOH-1555 (10/89) p. 1 of 2 VS-61