Trombley, James 11- `l%-Z-
NEW YORK STATE DEPARTMENT OF HEALTH .%
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Alan Trombley Male
. Date of Death Age If Veteran of U.S. Armed Forces,
December 8, 2014 40 yrs. War or Dates No
i- Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address 76 Mt. Hope Avenue
p Manner of DeathE Natural Cause ❑Accident ElHomicide ElSuicide ri❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, New York 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti r-nnrieroga 1564 68
['Burial Date Cemetery or Crematory
['Entombment1 2/1 1 /201 4 Pine View Crematory
Address
®Cremation Queensbury, NY
Date Place Removed
ZEi Removal and/or Held
and/or Address
` Hold
CO
O Date Point of
0 ❑Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
a Address
I
'' Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued 1 2/9/2 01 4 Registrar of Vital Statistics `7 7 , Cei-i-e---r,---
(signature)
District Number 1 564 Place Town of Ticonderoga
I- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 12I ij Place of Disposition t„t1,.. (i�..vtor..�
2 (address)
ILl
to
cc (section) (lot nu er) (grave number)
ci Name of Sexton or Per on in Char e of Premises t�k�� �/
(please print)
tLi Signature Title "'it h
(over)
DOH-1555 (02/2004)