Wrobleuski Jr, John A 1 It 0/
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
John J. Wrobleuski 7(2.. Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 8,2016 86 War or Dates Korean
1-- Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Jennifer Stratton
Address
Queensbury Family Health Center,Queensbury,NY 12804
Death Certificate Filed District Number Regissr,Nurr
City, Town or Village C/O Glens Falls _ 5601 ��
❑Burial Date Cemetery or Crematory
September 12, 2016 Pine View Crematory
❑Entombment Address
ID Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
�' Hold
N
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
2 Address
is
W:
d' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 j + 21 1'6 Registrar of Vital Statistics O b' ` k >
(si ture)
District Number 5601 Place ( `5- Fr 1, `S�P1 v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
cu Date of Disposition 11!3/k, Place of Disposition gM,utN ./ � oA J
(address)
W
re
(section) XI,—
number) (grave number)
pName of Sexton or Person in Charge of Premises dFX<< Ji1 fl
Z (plJase print)
W
Signature Title CWk:Mfik—
(over)
DOH-1555 (02/2004)