Bombard, Anna Pr ion
NEW YORK STATE DEPARTMENT OF HEALTA :e f
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anna Mary Bombard Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/ /2011 An years War or Dates
P of Death Hospital, Institution or
it , ow I
Street Address
Glens Falls Park St C�liens Falb N Y 12801
rier o ea Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ ndetermined ❑Pending
W. Circumstances Investigation
at Medical Certifier Name Title
AddrHoward E Silverberg M. D.
318 Broadway Fort Edward, N Y 12828
Death Certificate Filed District Number Register Number
City TowitaiiilAityy Cianc Fallc sAn1 172
LJBurial Date Cemetery or Crematory
i ❑Entombment 04/13/2011 Pine View Crematorium
Address
�Cfemation 0ueenchiiry, NY 12804 •
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
I= Hold
V
O Date Point of
IW
❑Transportation Shipment
Lt by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
nii Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01136
iii.i. Address
P O Box 277 Fort Ann. N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
U
CL
Permission is hereby granted to dispose of the human remains describ d abov74'# t
ted.
li Date Issued 04/13/2011 Registrar of Vital Statistics(�
(signature)
District Number 5601 Place Glens Falls /A/ t/M-K /a c0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t.
111 Date of Disposition t1_fly_Zo l( Place of Disposition 17.`,,,c v :c...„ c r_e on ek.j r ow.
2 (address)
tit •
ita
(section) (lot number) (grave number)
C5▪ Name of Sexton or Person in Cha e of Premises I t m ccky P)e,,c,el l<
Zr) �-� l (please print)
Signature GA,4. Title C C e.,,,4,Seti vietv,4
(over)
DOH-1555 (02/2004)