Bombard Sr, Floyd NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Floyd J. Bombard,Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 18,2015 69 War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village Lake George Street Address 38 Hubbell Lane
Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
Circumstances Investigation
Ili Medical Certifier Name Title
Paul Bachman
Address
3767 Main Street,HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number 7
City, Town or Village 5651
Burial I Date Cemetery or Crematory
September 21, 2015 Pine View Crematory
E Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z
Removal _ and/or Held
and/or Address
H Hold
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home __ 00037
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
dC,
Permission is hereby granted to dispose of the hu 'ns described a••ve as indicated.
Date Issued 9 / `1 s Registrar of Vital Statist' r' /,
( gnature)
District Number 5651 Place T/O Lake George
I certify that the remains of the decedent identified above were disposed of in accordance��^^ with this permit on:
WDate of Disposition 9/ular Place of Disposition ��Y;,,,,, Eww-aj,x,.;..,.
W (address)
Cl)
pOC (section) (lot number (grave number)
Name of Sexton or Person in Charge of Premisesir,.� lease print)
f -.
Signature Title MOO 17/7-
(over)
DOH-1555 (02/2004)