Dobler, Bernard NEW YORK STATE DEPARTMENT OF HEALTH P '5 0
Vital Records Section .� Burial - TransitPermit
Name First Middle Last Sex
Bernard J. Dobler Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 26, 2011 85 War or Dates World War II World War II
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death J Natural Cause ❑ Accident El Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
III Medical Certifier Name Title
O Dean Reali, M.D
Address
Hudson Headwaters Warrensburg, NY 12885
Death Certificate Filed District Number Register Num
City, TTgartztAtiifagis Glens Falls 5601
❑Burial Date Cemetery or Crematory
August 31, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Tn of Queensbury, NY
Date Place Removed
z ❑ Removal and/or Held
{ and/or Address
F Hold Pine View Crematorium
Date Point of
p ❑Transportation Shipment
ta; by Common Destination
O Carrier
[' Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
2 Address
Le
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8/zs 01 Registrar of Vital Statistics .,,\.)`�
(signature)
District Number 5o0 ) Place 6 tZV _s ) 1 1 S/ W
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition `i Is I ii Place of Disposition giait,a (rr"`ti,iv r ire-
M (address)
w
CO
Ce (section) (lot numb r) (grave number)
O tit'AtiiiName of Sexton or Per n in Charge of remises r eh"int
•
i (please print)
W Signature ir,4 Title CQCli i 0t-
(over)
DOH-1555 (02/2004)