Dombek, Walter NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Walter Dombek male
Date of Death Age If Veteran of U.S.Armed Forces,
February 3, 1993 78 War or Dates no
Place of Death Hospital, Institution or
W City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident ❑ Homicide ❑ Suicide Undetermined Pending
ILICircumstances Investigation
ut Medical Certifier Name Title
1,74 Mark Hoffman MD
Address
84 Broad Street, Glens Falls, New York 12801
Death Certificate Filed District Number Register
RI City,Town or Village City of Glens Falls
Date Cemetery or Crematory
®Burial February 5, 1993 Pine View Cemetery
Cremation Address
Queensbury, New York 12804
Z Date Place Removed
OI', 0 Removal and/or Held
i- and/or Hold ..::::.
Address
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cf. Date Point of
N' 0 Transportation by Shipment
Destination
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❑ Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Regan and Denny Funeral Home, Inc. 01602
Ng Address 26 Quaker Road, Queensbury, New York 12804
i-. Name of Funeral Firm Making Disposition or to Whom
i; Remains are Shipped, If Other than Above
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Address
i
Permission is hereby granted to dispose of the human rema' described above as indicated.
Date Issued 7b79 , Registrar of Vital Statistics �'��� � ��,r��
(signature)
District Number �j Place - k.e...i I / 2-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Z Date of Disposition •'- 1-„: 1-.= Place of Disposition / / ;/ ✓r( A --c-r• ,
W i, (address) _ i
w / Ii( 1\. rC&N ,11_r'
(section) . (lot number) (grave number)
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p Name of Sexton n in Charge of Premises A �i s;� -/ C_,. �'�� ; �.. .� ;-
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W Signature ( �� ..c / Title --- roc
7
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