Trombley Sr, Richard NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Charles Trombley Sr. Male
T' Date of Death Age If Veteran of U.S. Armed Forces,
yy July 16, 2015 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Greenwich Street Address
Manner of Death El Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title
William Papura, Dr.
Address
1134 Rt 29 Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Greenwich
❑Burial Date Cemetery or Crematory
O. July 21, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
" ❑ Removal and/or Held
and/or Address
Hold
-- Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
Ili;:
ElReinterment Date Cemetery Address
000 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 he-ebny granted to dispose of the human remains described above as indicated.
Date Issued 17 v)�c Registrar of Vital Statistics f�( a 1(
(signature)
ot 5157 �fi bt �y 4ilck
District Number Place
-i: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 07/21/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
•
(section) A (lot number (grave number)
Name of Sexton or Person in Charge of Premises (4, 11Lc.- c1.�'i1
( lease print)
yam: Signature Title
/i2 F
(over)
DOH-1555 (02/2004)