Trombley, Gwendolyn 41)10
NEW YORK STATE DEPARTMENT OF HEALTH A_ � ('
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gwendolyn Joan Ruth Trombley Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 21, 2011 War or Dates
Place of Death Hospital, Institution or
in City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death X❑ Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
8 Medical Certifier Name Title
�O Michael Guido MD,
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number ` O ) Register Numberr--(:f o
City, Town or Village Q
❑Burial Date Cemetery or Crematory
December 27, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
d ❑Transportation Shipment
tl! by Common Destination
p Carrier
❑ Disinterment Date Cemetery Address
❑ 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
Remains are Shipped, If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5) 2 2 i/ Registrar of Vital Statistics W c �> � W
(signature)V
District Number -5 6 0 / Place 6 t.2Jr, iS '�G 1 S , N V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11-2.1r-?„4 Place of Disposition R•HQ :1.Lai C ,vt4,. u M
(address)
W
U)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises < tn."„ -A.1 e(le
Z (please print)
W Signature Title cf aAlvc 1A S4
(over)
DOH-1555 (02/2004)