Bromley, Nelson NEW YORK STATE DEPARTMENT OF HEALTH r f' 1 1 Vital Records Section a 14 Burial - Transit Permit
Name First Middle Last Sex
Nelson Richard Bromley Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 10, 2012 85 War or Dates World War II
I' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
WL.
Manner of Death Natural Cause 0 Accident Ej Homicide El Suicide Undetermined Ei Pending
Circumstances Investigation
W Medical Certifier Name Title
( how.a5C'S `�
Address Cam,,,{b,,,,.i
I Cc r� 12. G76 , , Iz4.ot
h Certificate Filed District Number Register Nuf ber
Cit Town or Village (�ta&5. 4/4 Ay , 5 67a /y
❑Burial Date Cemetery or Crematory
May 11, 2012 Pine Vew Crematorium
. ❑Entombment Address
®Cremation Oueensbury,NY 12804
Date Place Removed
z ri Removal and/or Held
and/or Address
p Hold
O Date Point of
� ❑Transportation Shipment _
V' by Common Destination
O` Carrier
ElDisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
X' Address
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_ Permission is hereby granted to dispose of the human remains descri we ndi
Date Issued 05T7O/?.O(2—Registrar of Vital Statistics
(signature)
District Number (/ Place /e/7s /sc /6,1y 102 '/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition S II i Ill_ Place of Disposition ['H,U�„� , (�V..,
(address)
W
l
I4 (section) (lot n ber)) (grave number)
O Name of Sexton or Pe on in Char a of Premises 4(iviii..," Ara
z (please print)
ill Signature Title CifWAYc)tL
(over)
DOH-1555 (02/2004)