Trombley, Betty NEW YORK STATE DEPARTMENT OF HEALTH ea39
Vital Records Section • Burial - Transit Permit
Name First Middle Last Sex
Betty Eileen Trnmh1cy • F
Date of Death Age If Veteran of U.S. Armed Forces,
06-27-2014 65 War or Dates
1- Place of Death Hospital, Institution or
City, Town or Village V/so. G1 ens Fails Street Address 62 Saratoga Avenue
0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
kt Circumstances Investigation
Medical Certifier Name Title
E` .tC Pillemer MD
Address
glens Fa1- s Hospital_, Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City,Town or Village V/So. Glens Falls
i > El Burial Date Cem t�ry or Cr�mato
06-27-2014 tpine View Cryrematopry
II!!!:Eli:❑Entombment Address
®CremationIl
21 Quaker Road, Quo nsb , N 122804_
Date ar e Rem oved
30 Removal and/or Held
� and/or Address
U)
Hold
O Date Point of
tL D Transportation Shipment
a by Common Destination
mi Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homy•B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward, NY 12828
IN Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
It
LU
Permission is hereby granted to dispose of the human remai Aescribed ab as i dicated.
Date Issued 6-2 7-2 01 4 Registrar of Vital Statistics
signature)
District Number �l 5 a k4 Place d C (ens (s %l -
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition toltlIN Place of Disposition 4?'iU&, Cntretor=o—
a (address)
ua
cc (section) /� (lot number (grave number)
ta Name of Sexton or Person " Charge of Premises 64s1 A L JNi+r4
6please print)
g
Si nature ^ Title G `'v? 7t'
(over)
DOH-1555 (02/2004)