Groome, Joseph Burton .� 11 `1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records 10
Name First Middle }. ' Last Sex
Joseph Burton Groome 6 . Male
Date of Death Age If Veteran of U.S.Armed Fot `
12/08/2022 82 Years War or Dates
H Place of Death . -klgspital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑X Natural Cause Accident [ ]Homicide []Suicide FlUndetermined []Pending
W Circumstances l (Investigation
W Medical Certifier Name Title
CI Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 615
RBurial Date Cemetery,Crematory or Facility Name
12/12/2022 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
n. Date Point of
(/) Transportation Shipment
Q by Common
Carrier Destination
EDisinterment 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
1. Remains are Shipped,If Other than Above
2 Address
CC
W
11.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/09/2022 Registrar of Vital Statistics MeganNoln(Electronica11:y Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ IL 62
Z Date of Disposition I"2�IK�IL Place of Disposition
W (address)
W
NCC (section) 7 (/92 number) -�:�" (grave number)
0 :::::: °"
or Person in Charge of Premis ./ 1(prise print)(... Title
DOH-1555(07/18)p 1 of 2
1
U , . a ij
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#