Bromley, Roxanne NEW YORK STATE DEPARTMENT OF HEALTH # 7'2
a T
Vital Records Section .a Burial - Transit ansit Permit
Name First Middle Last Sex
Roxanne Bromley Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 7, 2016 58 War or Dates
Place of Death Hospital, Institution or
fa
usCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death IL.] Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
U; Circumstances Investigation
W Medical Certifier Name Title
Ageel A. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Nurr / Regist�Vrpper
City, Town or Village Glens Falls �� ff
❑Burial Date Cemetery or Crematory
April 12, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
w Date Point of
❑Transportation Shipment
CO by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued '-I ).?/ 16 Registrar of Vital Statistics (A) CJwrQ,.VJ...^✓ly
(signature)
District Number S `�/ Place S ` j 11 S N/ 1.�?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ul Date of Disposition 04/12/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) / (lot number) (grave number)
Name of Sexton or Person in Charge of P mises 64c~ .S
lease print)
ill Signature Title ''9"tztg—
(over)
DOH-1555 (02/2004)