Trombley, Frank NEW YORK STATE DEPARTMENT OF HEALTL4. >t Burial 1,
Vital Records SectionTransit ermlt
Name First M iddlo Last Sex
Frank A. Trombley Male
Date of Death Age If Veteran of U.S.Armed Forces,
I. April 29, 2013 War or Dates NO
Z Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address Indian River Rehabilitation and Health C
0 Manner of Death ®Natural Cause I=1 Accident 0 Homicide 0Suicide Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W
0 Address
Death Certificate Filed District Number �� Register Number jJ City,Town or Village Granville
❑Burial Date —( — 13
Cemetery or Crematory
Pine V, tea Cvelma toy i uvv,
❑Entombment Address l ,t�
Q Cremation �CA�t-t Cl 1 Ut�•�t�E4'�(
Z Date Place Removed
0 0 Removal and/or Held
and/or Address
I" Hold
i Date Point of
0 0 Transportation Shipment
0. by Common Destination
Carrier
Date Cemetery Address
Disinterment
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
1= Name of Funeral Firm Making Disposition or to Whom
X Remains are Shipped, If Other than Above
W Address
O.
Permission is her y ranted to dispose of the human remains tM1jias indicated.
t �i r Date Issued1� Registrar of Vital Statistics . �s MEW
(signature)
District Number 5--0E Place Granville,New York
P I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition S-I'13 Place of Disposition 2-1U'i.J C ( Oca
2 (address)
(sectio
n)) /�' (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pr mises )(i S 8 n,
2 Vte print)
Signature 1 L ,- Title COEit,W VIt_
(over)
DOH-1555 (02/2004)