Trombley, David NEW YORK STATE DEPARTMENT OF HEALTH b 5 7-
Vital Records Section ‘ ._ 4 Burial - Transit Permit
— r.,-
Name First Middle Last Sex
David Ronald Trombley Male
Date of Death Age if Veteran of U.S. Armed Forces,
September 7, 2016 70 War or Dates
Place of Death Hospital, Institution or
ut City, Town or Village Glens Falls Street Address 9 Montcalm Street
01 Manner of Death 0 Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0 AgeelA. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5 6 0 ) 4 5 -7
❑Burial Date Cemetery or Crematory
September 9, 2016 Pine View Crematory
''❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
O❑ Removal and/or Held
and/or Address
Hold
C Date Point of
a. ❑Transportation Shipment
CO by Common Destination
C Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 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
EL.. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued q 1 v i ! 6 Registrar of Vital Statistics tCAAln—NR.
(signature)
District Number 5 6 0/ Place 6 s co, l ) S`N y
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 09/09/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Ui
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises ��,s^ r 51 4a1(JL
�7� ( (please pnnt)
Signature G' Title ( tb��e-
9
(over)
DOH-1555 (02/2004)