Trock, Stephine S 4G
NEW YORK STATE DEPARTMENT OF HEALTH - 41111) , -i;Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Stephanie Trock Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/18/2022 60 Years War or Dates
F.. Place of Death Hospital,Institution or
1Z City,Town or Village South Glens Falls Village Street Address 129 Saratoga Avenue 118,South Glens Falls Village,New York 12803
0 Manner of Death ❑X Natural Cause Accident Homicide ESuicide nUndetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed Village Of South Glens Falls District Number Register Number
City,Town or Village 4524 4
EBurial Date Cemetery,Crematory or Facility Name
07/25/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
F. Hold Address
CO
0
Ct. Date Point of
CO❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
0 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
-. 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 07/25/2022 Registrar of Vital Statistics joy Oarthotomew(ECectronicaJCy 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:
I—
W Date of Disposition 9.-26'....zo Zz Place of Disposition Pt, ti1"c_ (,v �G r i-e.pi "r rj
W
cn
cc (section) (lot nu ber/ (grave number)
8 Name of Sexton or Person in Charg f Pre ises �4)'/1/a"rD ��
z
. (please print)
W Signature g Title ef.,errcterf
DOH-1555(07/18)p 1 of 2
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#