Trombley, Paul Kim Iic
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Paul Kim Trombley Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/27/2022 67 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village South Glens Falls Village Street Address Main Street And 5th Street,South Glens Falls Village,New York 12803
W Manner of Death g
� �Natural Cause Accident �Homicide Suicide Undetermined ❑Pendin
W Circumstances Investigation
V
W Medical Certifier Name Title
O Anthony Pemiciaro Coroner
Address
6012 County Farm Road,Ballston Spa Village,New York 12020
Death Certificate Filed Village Of South Glens Falls District Number Register Number
City,Town or Village 4524 30
Burial Date Cemetery,Crematory or Facility Name
03/03/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
g❑Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
a Date Point of
to
Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
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
F. Remains are Shipped,If Other than Above
5 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2022 Registrar of Vital Statistics Joy Bartholomew(Electronically Signed)
(signature)
District Number 4524 Place Village Of South Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH W /address),Date of Disposition 314 I ZZ Place of Disposition ram^
W
Q (section) (lot number) e, (grave number)
8Name of Sexton or Person in Cha7 of Premises //I(i 4''ppL_..
(piea(#e print)
W Signature / Title VV tf
DOH-1555(07/18)p t of 2
) t eo
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on _, 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#