Bombard, Angel Lynn - L711
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit hermit
Bureau of Vital Records , 4-
Name First Middle Last Sex
Angel Lynn Bombard Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/06/2020 33 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 29 McDonald Street Apt.A,Glens Falls, New York 12801
WW Manner of Death
Natural Cause ❑Accident 0 Homicide ❑Suicide 11 Undetermined a Pending
U Circumstances Investigation
W Medical Certifier Name Title
Q
Paul Bachman MD
Address
3767 Main Street,Warrensburg Town,New York 12885
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 560
❑Burial Date Cemetery,Crematory or Facility Name
12/10/2020 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury Town,New York
0 Donation
0 Removal Date Place Removed
and/or and/or Held
pto Hold Address
0
G. 1-1 Date Point of
co Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
0.1
2 Address
CE
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/10/2020 Registrar of Vital Statistics $'pdertf7narrew Curtis(EYectronicalr Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 12'll i TOPlace of Disposition -7.-IL —
2 (address)
W
t!)
Cr (section) ((lot number) (grave number)
0 Name of Sexton or Person in Charge o Premises � t'/p/eas �- �0h014�
z print
W SignatureJ Title (144$1111-Vi
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01 1221
Receipt
Human remains of ; delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#