Trombley, Kevin P 3/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kevin C. Trombley Male
Date of Death Age If Veteran of U.S. Armed Forces,
4/16/2018 56 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 140 Cronin Road
p, Manner of Death n Natural Cause _Accident [ Homicide n Suicide n Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
0 Anthony Petracca,MD
Address
3 Irongate Center,Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury
❑Burial Date Cemetery or Crematory
❑Entombment April 18, 2018 Pine View Crematorium
Address
IN Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
Hold
N
O Date Point of
O.
n Transportation Shipment
p by Common Destination
Carrier
[I Disinterment Date Cemetery Address
(�Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y-- g- a,6 g Registrar of Vital Statistics ' L��
(signature)
District Number c:3 c,J--f Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 'ri Place of Disposition Ii Ij, (,.,
2 (address)
qj,is
(section) (lot number) (grave number)
Op Name of Sexton or Person in Charge of Premises (.-f S e»•'d+
Z /9 Arse print)
Signature Gvt Title 1itinni
(over)
DOH-1555(02/2004)