Trowbridge, Victoria 1/41
NEW YORK STATE DEPARTMENT OF HEALTH p
Vital Records Section - Burial - Transit Pe
rmit
Name First Middle Last Sex
Victoria Lee Trowbridge Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/09/2012 62 years War or Dates
Place of Death Hospital, Institution or
5 City, Tows 1i .;,f�- Street Address
�C7� XX C,IanG Falls Ins Falls N Y 19801
0 Manner of Death �j l�,atural Cause ❑lAccident El Homicide ❑Suicide El Undetermined ❑Pending
y Circumstances Investigation
is Medical Certifier Name Title
AgPelA Giilani M D
Address
102 Park Street Glens Falls, N Y 12801
D--th Certificate Filed District Number Register Number
TompAyi XX Glens Falls 5601 58 '
UBurial Date Cemetery or Crematory
❑Entombment 02/10/2012 Pineview Crematory
Address
`` Jc remation Queensbury, N Y 12804
Date Place Removed
Z Removal and/or Held
2 ❑and/or
l i,; Address
0,
Hold
0 Date Point of
a.❑Transportation Shipment
.0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
aii
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
•
l •
P` Permission is hereby granted to dispose of the human remains de ribed abo e as i 'c ed.
Date Issued 02/10/2012 Registrar of Vital Statistics � ‘474-
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
LU Date of Disposition fete Ioi Oa_ Place of Disposition P.0404.4-1 »:foriv�.
2 (address)
LU
CO
CC (section) i t (lot numbe (grave number)
gi Name of Sexton or Pe on in Charg of Premises G ^r" i
z ' (please print)
iLi Signature Title �I.
g Af
(over)
DOH-1555 (02/2004)