Gralewski, Jean .. 37
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Jean O. Gralewski I Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 22,2012 86 War or Dates
i,., Place of Death Hospital, Institutiorfe Stanton Nursing& Rehabilitation
Z City, Town or Village Queensbury Street Address Centre
0 Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
tit Circumstances Investigation
W Medical Certifier Name Title
0 Patricia Auer Dr.
Address
,Glens Falls,NY 12801
Death Certificate Filed District Number Re.gister Number
City, Town or Village Queensbury 5657 [CIA
❑Burial Date Cemetery or Crematory
August 23,2012 Pine View Crematory
11 Entombment
Address
Ell Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
F' Hold
N
0 Date Point of
i
N Transportation Shipment
a by Common Destination
Carrier
(Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to 1 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
F_ Remains are Shipped, If Other than Above
2 Address
CZ
tL
Permission is hereby granted to dispose of the human e ains described ove as indicated.
Date Issuedj\ A �� Registrar of Vital Statistics �_ Q _ (m A
(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:
U.1 Date of Disposition 1-13-It Place of Disposition 1/i.cvctw Co ,ftvA
W (address)
N
iY (section) ZIr (lot number) (grave number)
0 Name of Sexton or Person in Charge of remises rrA 411"
Z (please print)
111
Signature Title GMeM►1i-C()l_
(over)
DOH-1555 (02/2004)