Trombley Sr, Charles 4 Nit # 10
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
vt, Name First Middle Last Sex
f{ Charles A. Trombley,Sr. Male
�`f Date of Death Age If Veteran of U.S. Armed Forces,
November 29, 2014 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 175 Luzerne Road
Manner of Death Undetermined Pending
0 Natural Cause �Accident n Homicide n Suicide 0. � n
Circumstances Investigation
Medical Certifier Name Title
Thomas Coppens,MD
Address
r`' 3 Irongate,Glens Falls,NY 12801
```= Death Certificate Filed District Number Register Number
s, City, Town or Village Queensbury,NY 5657 I n
El Burial Date Cemetery or Crematory
12/2/2014 Pine View Crematorium
El Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
u Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
(j' Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
;'g Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
f
Address
t
Permission is hereby granted to dispose of the human remains describe above as indicated.
Date Issued la l i 13-U1 y Registrar of Vital Statistics 4hC-,___ �i . /L-c)...___
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance/with this permit on:
WDate of Disposition (Z- , -{/ Place of Disposition .4 U..... C,rw-tar*_
2 (address)
W
CO
ft (section) (lo number) (grave number)
QName of Sexton or Person 'n Charge f Premises Sprv, r-
Z ( lease print)
LU Signature Title NI.Al at'
(over)
DOH-1555(02/2004)