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Trombly, Randy Richard I30Z. NEW YORKSTATE DEPARTMENT OF HEALTH 1 \" Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Randy Richard Trombly Male Date of Death Age If Veteran of U.S.Armed Forces, 12/09/2020 72 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc Manner of Death © Natural Cause ❑Accident 1:1Homicide ❑Suicide El Undetermined ❑Pending W Circumstances Investigation 1U Medical Certifier Name Title a Brittany Miske NP Address 131 Lawrence St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Saratoga Springs 4501 645 Burial Date Cemetery,Crematory or Facility Name 12/14/2020 Pine View Crematory ElEntombment Address ElCremation Queensbury Town,New York Donation 0 Removal Date Place Removed [21and/or and/or Held H V Hold Address ) 0 a Date Point of U) Li Transportation Q by Common Shipment Carrier Destination El Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom }... Remains are Shipped,If Other than Above g Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/14/2020 Registrar of Vital Statistics John Paul 2Franck(E(ectronica1Cy Signed) (signature) District Number 4501 Place Saratoga Springs, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: If— W Date of Disposition 12 1 it No Place of Disposition 2 '(address) W (section) A(lot number) (grave number) tt0 Name of Sexton or Person in Charge of Pr .ses n c �' 1W (plea print) W Signature Title CI 43 g DOH-1555(07/18)p t of 2 Public Health Law Sec. 4145(2b) O 1 4:2 b 2 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#