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Worbel, Brenton NEW YORK STATE DEPARTMENT OF HEALTH £� # 6 ` l Vital Records Section Burial - Transit Permit Name First Middle Last Sex Brenton Michael Wrobel Male Date of Death Age If Veteran of U.S. Armed Forces, September 13, 2017 28 War or Dates Place of Death Hospital, Institution or CI City, Town or Village Moreau Street Address 3 B Jamaica Road Manner of Death❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined E Pending fka Circumstances Investigation s- Medical Certifier Name Title Michael Sikirica , Dr. Address 50 Broad Street Ste 1 Waterford, NY 12188 Death Certificate Filed District FIyrr er,,1 Register ember City, Town or Village Moreau L�j(w`� /J- U ❑Burial Date Cemetery or Crematory September 18, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date l Place Removed ❑ Removal I and/or Held and/or Address E Hold Date Point of ❑Transportation Shipment .' by Common Destination ri Carrier Date Cemetery Address ❑ Disinterment `'❑ Reinterment Date Cemetery Address Permit Issued to Registration Number '.` Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 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 human remains described •,Sv�as indicated. Date Issued O9// /c?oi 7 Registrar of Vital Statistics ,el/ IW (sig ature) District Number C/5?0 Place 35( tc(rbds i2t%o&f.// � /)a')I = I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 09/18/2017 Place of Disposition Quaker Road Queensbury,NY 12804 (address) la (section) (lot number) (grave number) Name of Sexton or Person in Charge of Pr mises ,,10p a.i11*` (plelase print) a CRE�� - Signature Title (over) DOH-1555 (02/2004)