Stomski, John NEW YORK STATE DEPARTMENT OF HEALTH r 41 t to
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
. John Arthur Stomski Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 12, 2012 77 War or Dates
. Place of Death Hospital, Institution or
N<, City, Town or Village Street Address The Orchard Nursing & Rehabilitation Cent
f Manner of Death 0 Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
Medical Certifier Name Title
Address
Death ificate Filed District Number Register Number
Ci , o or Village GRANUtt.-1- 5'156 aS
11
0 Burial Date Cemetery or Crematory
August 14, 2012 Pine View Crematory
0 Entombment
Address
®Cremation
Date Place Removed
El Removal and/or Held
and/or Address
Hold
Date Point of
E 0 Transportation Shipment
by Common Destination
' Carrier
Disinterment Date Cemetery Address
Reinterment
i Date Cemetery Address
Permit Issued to Registration Number
4.N Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
" ' 136 Main Street, South Glens Falls NY 12803
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 b$(l y IaOI , Registrar of Vital Statistics 4 ,
(si nature)
h. District Number si5-6 Place -TDu9tu o F Gr2A-4VlLt.
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/14/2012 Place of Disposition -PiN,UttuJ Ct-t-A-vrkb-,
(address)
(section) 4 , (lot number- (grave number)
` Name of Sexton or Person in Cha ge of Premises th0 •w4#
(please print)
�_' Signature Title Cs.,MI dt
(over)
DOH-1555 (02/2004)