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Wrobel, Rose M. # 130g NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Rose M Wrobel Female Date of Death Age If Veteran of U.S.Armed Forces, 12/11/2020 63 Years War or Dates �.. Place of Death Hospital,Institution or Z City,Town or Village Gloversville Street Address Nathan Littauer Hospital Manner of Death W Undetermined Pending©Natural Cause 0 Accident Homicide 0 Suicide Circumstances Investigation C.) Medical Certifier Name Title Margaret Luck Coroner Address 223 West Main Street,Johnstown,New York 12095 Death Certificate Filed District Number Register Number City,Town or Village Gloversville 1701 239 ❑Burial Date Cemetery,Crematory or Facility Name 12/15/2020 Pineview Crematory ❑Entombment Address lCremation Queensbury Town,New York ElDonation Removal Date Place Removed and/or and/or Held H N Hold Address 0 a Date Point of N ❑Transportation Q by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above a Address W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2020 Registrar of Vital Statistics Jennifer Mazur(Electronically Signed) (signature) District Number 1701 Place Gloversville, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition j Z I go 170 Place of Disposition c, 2 (address) IJJ CC (section) f 7 (lotnumberJ (grave number) 0 Name of Sexton or Person in Charge of P ' es �` '"a Z (pleesse print)IlJ Signature Title 6 •I,1 -761‘ - DOH-1555(o7/18)p t of 2 Public Health Law Sec. 4145(2b) 014?9 8 Receipt Human remains of delivered on • , 20 I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#