Groome, Peter NEW YORK STATE DEPARTMENT OF HEALTH 1 g y
0 t.
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
a, Peter E. Groome Male
F. , Date of Death Age If Veteran of U.S. Armed Forces,
; .' 2/7/15 54 War or Dates No
, Place of Death Hospital, Institution or NY
City, Town or Village Glens Falls Street Address Glens Falls Hospital, Glens Falls
Manner of Death El Natural Cause 0 Accident El Homicide El Suicide El Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
LibMD
TV t Address
c,4 100 Park Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register umber
City, Town or Village Glens Falls 5601 R
0 Burial Date Cemetery or Crematory
2/9/15 Pine View Crematory
0 Entombment Address
'oCremation Quaker Road, Queensbury, NY
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
u Transportation Shipment
.. by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01 078
Address
;, 136 Main St. So.Glens Falls, NY 12803
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 describ d a�.bpve s in t d.
1CI4 Date Issued C�Z/O911J S Registrar istrar of Vital Statistics Z !rl
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(signature)
:; District Number 5601 Place Glens . Falls, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 710-lr Place of Disposition 1i4Alf,--1 e.,..-p,..."
(address)
(section) /4 (lot nufpbe�r)) (grave number)
l�hN ,.. .mit-
t Name of Sexton or Person in Char a of Premises print)
. Signature "` Title � �
Sg
(over)
DOH-1555 (02/2004)