Trombley, Genevieve NEW YORK STATE DEPARTMENT OF HEALTI i;. , 3 Vital Records Section ` ` Burial - Transit Permit
Name First Middle Last Sex
Genevieve Jolene Emerson Trombley Female
Date of Death Age If Veteran of U.S.Armed Forces,
December 21, 2011 k,,{-„.t War or Dates
Place of Death Hospital, Institution or
L i City, Town or Village Glens Falls Street Address Glens Falls Hospital
inh Manner of Death rnill .i Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
t9 Circumstances Investigation
W Medical Certifier Name Title
Michael Guido MD,
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number 5.(..,�j Register umber
City, Town or Village
❑Burial Date Cemetery or Crematory
December 27, 2011 Pine View Cemetery
❑Entombment Address
®Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
G and/or Address
E Hold
CO Date Point of
Q ❑Transportation Shipment
aA by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
EAddress
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /2/ 2 3)1/ Registrar of Vital Statistics c&)j-, p LAijA- '
(signature) U
District Number 5 60 ) Place 6 S S o. `\5 , 1\1 y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 12-1Y-- I Place of Disposition ?Mt u.'ew C.resae4(9f' O vii
W (address)
V?
(r (section) (lot number) (grave number)
0
• Name of Sexton or Person in Charge of Premises 1 ,:w►n�ty Qti•Iefle
z �� /;1 (please print)
W Signature Z, Title Cry «. +4-•
(over)
DOH-1555 (02/2004)