Bombard, Carlos 4 4 NEW YORK STATE DEPARTMENT OF HEALTH - # 6/5r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r Carlos E. Bombard Male
I Date of Death Age If Veteran of U.S. Armed Forces,
July 21, 2016 81 War or Dates
Yf: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
ti r; Wendy Steinhacker
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number, s
' ri City, Town or Village Glens Falls 5601
❑Burial Date Cemetery or Crematory
July 25, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
9. and/or Address
H Hold
co
0 Date Point of
to I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:,;... Permit Issued to Re istration Number
r. g.
},;.� Name of Funeral Home Regan Denny Stafford Funeral Home 01443
r'r Address
0: 53 Quaker Road, Queensbury,NY 12804
r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
r
.•*, Permission is hereby granted to dispose of the human remains desc ibed above as ' i ted.
fir, Date Issued (�J/Z�ZD/6 Registrar of Vital Statistics �,� G sic
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{} (signature)
:: District Number 5601 Place Glens Falls
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
C
W Date of Disposition ?CZrilt, Place of Disposition iatOtt, r4ne ^,,
2 (address)
W
0 (section) Lti-pL—
lot number) (grave number)
QName of Sexton or Person in Charge of Premises At-4
Z (pletne print)
W 2._
Signature 1
Title Ckm VA
(over)
DOH-1555(02/2004)