Phalen, Jacqueline NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
I` Vital Records Section
Name First Middle Last Sex
Jacqueline A. Phalen Female
Date of Death Age If Veteran of U.S.Armed Forces,
1. November 29, 2006 73 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death 0 Natural Cause Ell Accident 0 Homicide OSuicide Undetermined Pending
W Circumstances Investigation
Medical Certifier Name Title
W Dr. Joseph D'Agostino, M.D. Dr.
Q Address
17 Baywood Drive, Queensbury, NY 12804
Death Certificate Filed District Number o Register Number
City,Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
December 4, 2006 Pine View Cemetery
❑Entombment Address
0 Cremation Quaker Road Queensbury, NY 12804
L Date Place Removed
0 El Removal and/or Held
- and/or Address
i" Hold
14 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
= Date Cemetery Address
ti 0 Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01140
Address
123 Main St. , Argyle, New York 12809
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
IL
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
j
Date Issued )2-)l/ 0 6 Registrar of Vital Statistics VpAjQA 4 Cti l ir+
(signature)
District Number 5 6C) f Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Date of Disposition 12/04/2006 Place of Disposition Pine View Cemetery
(address)
W
CI (section) of number) (grave number)
O Name of Sexton or Person in Charge of Premises ( k el S t nni'tt'
Z A (please print)
W f Title (tell.A r
Signature �-1UM �..t�+�►�'" ,
(over)
DOH-1555 (02/2004)