Fowler, Ervin Winferd it 11
NEW YORK STATE DEPARTMENT OF HEALTH �. Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ervin VVinferd Fowler fie
Date of Death Age If Veteran of U.S.Armed Forces,
0424/2022 89 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
INManner of Death El Natural Cause ❑Accident I=1 Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
a Wendy Steinhacker PA
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
Cit E,Town or Village 5657 79
Burial Date Cemetery,Crematory or Facility Name
04252022 PIe View CrematoryEntombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
F and/or and/or Held
N Hold Address
O
d Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
pReinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Hone 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped,If Otherthan Above
5 Address
CC
ILI
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0425/2022 Registrar of Vital Statistics Caro8rrre9 artlerBartvrgfectrvakalryS ne4
/signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ,,��
WDate of Disposition Li ill 1 VLPlace of Disposition • r,q�� /i"�r'.�
2 add-ess)
W
N (section) (lot number) (grate number)
� i c
8 Name of Sexton or Person in Charge of Pre ises (LI-
L-- l'`T`fit
zease print) /�tN Signature �.� Title ` �W��
DOH 1555(07/18)p 1 of 2
► ..
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#