Osowiecki, Robert t . \
NEW YORK STATE DEPARTMENT OF HEALTH �i2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert H. Osowiecki Male
Date of Death I Age If Veteran of U.S. Armed Forces,
April 20,2014 I 64 War or Dates
Place of Death Hospital, Institutiorl%1Tiirondack Tri-County Health Care
tZ City, Town or Village Johnsburg Street Address LI Center
a Manner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending
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Circumstances Investigation
Lu 0 Medical Certifier Name Title
James Hindson Dr.
Address
Main St.,Warrensburg,NY 12885
Death Certificate Filed I District Number Register Number
City, Town or Village Johnsburg 5655 ;/`1
❑Burial Date Cemetery or Crematory
❑Entombment April 22,2014 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_ Hold
0 Date I Point of
n.
y Transportation 1 Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date i 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
I— Remains are Shipped, If Other than Above
2 Address
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Permission is hereby granted to dispose of the human re ains described bove as i icated.
Date Issued -14.oZD.-- ILI Registrar of Vital Statistics 0 ck,
(signature
District Number Johnsburg Place 5655
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z � tdrw—
Date of Disposition ��Z3�W Place of Disposition lnt H.J
2 (address)
ILI
re g (section) �� q(lot number) (grave number)
pName of Sexton or Person in Charge f Premises tr,, r trl
Z (please print)
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Signature apt,- Title 1lZ42i f0(.
(over)
DOH-1555 (02/2004)