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Bombard, Victor NEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Victor H.Bombard Last Sex Date of Death Male ' 10/30/2019 Age If Veteran of U.S.Armed Forces, 91 Years War or Dates 1945-1948 Place of Death City,Town or Villa a Hospital,Institution or W g Queensbury Town Street Address Warren Center for Rehabilitation and Nursing p Manner of Death Natural Cause W X Accident Homicide Suicide Undetermined Pending Medical Certifier Name Title Circumstances Investigation Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed City,Town or Village Queensbury District Number Register Number i 5657 159 ©Burial Date Cemetery,Crematory or Facility Name Entombment Address Pine View Cemetery Address ❑Cremation Queensbury Town,New York '. Donation ❑Removal Date Place Removed and/or and/or Held Hold Address ©' Transportation Date Point of 1] by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Name of Funeral Home Regan Denny Stafford Funeral Home Registration Number Address 01443 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom (=- Remains are Shipped,If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. ' Date Issued 10/31/2019 Registrar of Vital Statistics Camrnex�lgarde Bar6er(EYectmnically rg District Number (signature/ 5657 Place Queensbury, New York 1 certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Place of Disposition N J� /addhasl/ O Name of Sexton or Person in Cha e l (lot number/ (grahenumber/ Z B mises �DetO„t7iC (�. � 7-- ItJ Signature , �101-sep Title DOH-1555 l07/18)p t of 2 Public Health Law Sec. 4145(2b) U1035 } Receipt Human remains of `r '' �' �` �� delivered on �'� ✓ , 20,dI` � f ,�✓l✓'�'f�...1,;' i:r�;..����t+/'" t ...,....-.yp a../� / �n.�k �^ Ct ��,.' .i�...1. ' a ne View Cemetery Representing the funeral home named. ri rmit Official Funeral Directors Reg.or License# `J � s +�