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Trombly, Helen t sft32 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial_ - Transit ermit [ , Name First Middle Last Sex Helen J. Trombley Female Date of Death Age If Veteran of U.S. Armed Forces, 1 -4 July 10, 2013 83 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death .i Natural Cause n Accident n Homicide ❑ Suicide ❑ Undetermined ri❑ Pending tit Circumstances Investigation _-.a, Medical Certifier Name Title __ Gamal Khalifa, Dr. Address 100 Park Street Glens Falls 12801 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls ,GQ) 290 ❑Burial Date Cemetery or Crematory July 15, 2013 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 ❑ Removal Date Place Removed and/or Held and/or Address p Hold k. Date Point of ❑Transportation Shipment S by Common Destination Carrier l ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address 'T: Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01079 --a Address , 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address 1 Permission is herb granted to dispose of the human r ains ribed abokas indica •d. = Date Issued C7 i i 001 Registrar of Vital Statistics 0'(J � 07 r ture) District Number `�(0(1 Place � i IF=: I certify that the remains of the decedent identified above were sposed of in accordance with this ermit on: ilk Date of Disposition 07/15/2013 Place of Disposition Quaker Road Queensbury,NY 12804 ` ; (address) lit (section) (lot number) c (grave number) Name of Sexton or Person in Charge of Premisesr„{ �,,- J;?„ (ple se print) Signature Title (Tl ntrat (over) DOH-1555 (02/2004)