Trombley, Audrey NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
74 Name First Middle Last Sex
r 4 Audrey I. Trombley Female
f :
�-=f Date of Death Age If Veteran of U.S. Armed Forces,
,�, December 10,2014 84 War or Dates
{ Place of Death Hospital, Institution or
• City, Town or Village Queensbury Street Address 191 Luzerne Road
Manner of Death U Natural Cause 7 Accident Homicide n Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
,, Robert Love,MD
,;r
Address
f Glens Falls,NY
:%r Death Certificate Filed District Number Register Number
y Cit Town or Village (c)b
y, g Queensbury,NY 5657
❑X Burial Date Cemetery or Crematory
April 27, 2015 St. Alphonsus Cemetery
❑Entombment Address
❑Cremation Queensbury, NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E" Hold •
a
O Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
I!!`. Permit Issued to Registration Number
,.,, Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
f•f Address
go 407 Bay Road, Queensbury, NY 12804
};;
Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
� f
Address
1 -
Permission is hereby granted to dispose of the human r ains described above as indicated.
/t/. Date Issued Li Registrar of Vital Statistics �. ��
�,. (signature)
Ax A,,,,:, District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit oAn:
W Date of Disposition qj17I i 5 Place of Disposition pV\r;'_ S`- I Uje2JY201'.^ y�
W (address) 4
w C Z0 Z
g
(se o ) L �i of num er) (grave number)
Name of Sexton or Person in Charge of Premises CA-.,N.
`Z please p►nt) /
Signature Title r ,r\ct pv/
y
(over)
DOH-1555(02/2004)