Warnecke, Robert D 4 /—* # ki3
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records `\...._i Burial - Transit Permit
Name First Middle Last Sex
Robert D.Warnecke Male
Date of Death Age If Veteran of U.S.ArmeJ' Orces,
10/14/2022 90 Years War or Dates
i. Place of Death Hospital,Institution or
Z City,Town or Village Minerva Town Street Address 234 County 34 Route, Minerva Town, New York 12857
ILI
WManner of Death Natural Cause Accident []Homicide [IISuicide Undetermined Pending
U Circumstances Investigation
LU Medical Certifier Name Title
Kellie Valentine Coroner
Address
PO Box 132,Elizabethtown Town,New York 12932
DeaRth Certificate Filed Town Of Minerva District Number Register Number
City,Town or Village 1557 4
Burial Date Cemetery,Crematory or Facility Name
10/22/2022 Pine View Crematory
Entombment Address
EICremation Queensbury Town,New York
Donation
--
Z Date Place Removed
O 0 Removal
and/or and/or Held
F- Hold Address
N
0
0. Date Point of
U)IIITransportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Date Cemetery Address
E Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
5 Address
CC
Ill
0" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/18/2022 Registrar of Vital Statistics 'Theresa Fish(ECectronicafySigned)
(signature)
District Number 1557 Place Town Of Minerva
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I. � i/ /!
Z Date of Disposition i 0 sty)2Z Place of Disposition 1 n. Yi /.-4A,0-__
W
2 (address)
W
N (section) (lot number) (grave number)
0 C' cc µ
Name of Sexton or Person in Charge of Premises :N I�.. Jtmrt t I
z L i7,� (p! se print)
W Signature /-�/�/ Z Title tiisineiv2iL
DOH-1555(07/ia)pi of 2
11. +.f
,
Public Health Law Sec. 4145(2b) •
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ` .'