Topoleski, Mark tt
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YORK STATE DEPARTMENT OF HEALTH* Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Mark A. Topoleski Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 15,2011 24 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury 1 Street Address 113 Meadowbrook Road
iManner of Death Natural Cause X Accident 1 I Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
a Timothy E.Murphy Mr
Address
> 52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number Regi ter mber
City, Town or Village Queensbury 5657 c�
D Burial Date Cemetery or Crematory
0 Entombment April 19,2011 Pine View Crematory
Address
1I Cremation Quaker Rd.,Queensbury, NY 12804 _
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
N I 1 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 00035
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i. Remains are Shipped, If Other than Above
2 Address
W'
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued' \ I,I g�O Registrar of Vital Statistics CA.. �0 fly
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 11-1'~i I Place of Disposition �,04 to....) C ct.OfI,,,`
uJ (address)
U)
CL
(section) /� (lot n�er) (grave number)
Z Name of Sexton or Perso in Charge of remises C r,,}� L . h,.p4t-
(please print)
W Signature L Title aE.hj►��fit.
(over)
DOH-1555(02/2004)