Bromley, Levi ff
NEW YORK STATE DEPARTMENT OF HEALTH • S�L
Vital Records Section Burial - Transit Permit
'' Name First Middle K Last Sex
x `"
f� Levi B. Bromley Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/11/2014 30 War or Dates No
Place of Death Hospital, Institution
City,Town or Village City of Albany otStreet Address 260 Madison Ave.
Manner of Death Natural Undetermined Pending
❑ ❑ Accident ❑ Homicide ❑ Suicide ❑
14 Cause Circumstances Investigation
itit)" Medical Certifier Name Title
14 Michael Sikirica MD
Address
112 State. St. Albany, NY 12202
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1732
Date Cemetery or Crematory
❑ Burial 09/17/2014 Pine View Crematorium
❑ Entombment Address
® Cremation Town of Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
h' Hold
CO
O Date Point of
tL Transportation Shipment
co: ❑ By Common p
Q Carrier
Destination
❑ Date Cemetery Address
Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued To Registration Number
Name of Funeral Home Jillson Funeral Home 00885
Address
v 46 Williams Street Whitehall, NY 12887
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
E Address
11G
QL Permission is hereby granted to dispose of the human remains described above as indicated /�
Date 09/16/2014 \.�.� / -7.7 •
Issued Registrar of Vital Statistic ignature) `/
if
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance
twith this permit on:
ii Date of Disposition Rlig/ly Place of Disposition Et�►iLL .• Cr _is--
�! (address)
w
ce (section) (lot number (grave number)
0
0
+Z Name of Sexton or Person in Charge of Premises Ai ipi"
(please print)
Signature (.Lfp) 4,- Title C OA.Pi
(over)
DOH-1555(02/2004)