Trombley, Estella NEW YORK STATE DEPARTMENT OF HEALTH 4
Vital Records Section Burial - Transit Permit
9..
:. :. Name First Middle Last Sex
Estella L Trombley Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 13, 2014 84 War or Dates
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Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 175 Luzerne Road
�: Manner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
j�` Circumstances Investigation
Medical Certifier Name Title
P. Thomas Coppens M.D.
Address
3 Irongate Center,Glens Falls,NY 12801
:w: Death Certificate Filed twee(1S 1w(0 District Number Register Number
ii City, owl9kr Village _ ' -1 5,,..)1 33
❑Burial Date Cemetery or Crematory
March 17, 2014 Pine View Crematorium
❑Entombment Address
❑i Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
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Removal and/or Held
and/or Address
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0 Date Point of
yTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
:a' Name of Funeral Firm Making Disposition or to Whom
gi Remains are Shipped, If Other than Above
Address
` : Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3+ l41 Z-014- Registrar of Vital Statistics ---I2.• �.41L NA. ARs\
(signature)
:g: District Number 5D Place _al5 � Ji\
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition -1 7-/4' Place of Disposition -PIvvt\I,,�,J o ,1 h ei
2 (address)
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re (section) / (lot number) (grave number)
pName of Sexton/r P rson, arge of Premises J Co 4 Rp:v I.A-n G
Z ;Peafnt),,,JjW Signature 1a Title C �g%�',/A
(over)
DOH-1555(02/2004)