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Bombard, Jeffrey Alexander it p NEW YORK STATE DEPARTMENT OF HEALTH Transitrin Burial - Per Bureau of Vital Records Name First Middle Last Sex Jeffrey Alexander Bombard Male Date of Death Age If Veteran of U.S.Armed Forces, 10/27/2021 54 Years War or Dates 1H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital ILI p Manner of Death © Natural Cause ❑Accident ❑Homicide El Suicide I=1 Undetermined El Pending W 0Circumstances Investigation W Medical Certifier Name Title II Mathew Varughese DO Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 468 ❑Burial Date Cemetery,Crematory or Facility Name 10/28/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York 0 Donation Z Removal Date Place Removed and/or and/or Held H N Hold Address 0 Date Point of to Li Transportation Shipment Q by Common Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address C uJ 0' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/28/2021 Registrar of Vital Statistics 44.6ertAndre'w Curtis(E(ectronica((y 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: IH t Z Date of Disposition I PI Ill Place of Disposition �,l �"'— W (address 2 W LCLC (section) A(lot number) (grave number) o Name of Sexton or Person in Char of Premises 1 '��� Z (pleale grin if :VA Title if:VA tip 4 Signature DOH-1555(07/18)p 1 of 2 1 52 % Public Health Law Sec. 4145(2b) Receipt Human remains of ' ,. t'r,'') :' R'' delivered on ' , 24 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#