Conklin, Phyllis t RX'e�ate/Time 05/19/2017 11:08 P.001
NEW YORK STATE DEPARTMENT OF HEALTH CORYa� . Transit Permit
Vital Records Section `
Middle Last Sex
`` Name J. Conklin Female _
PhyllisPhy
�" Date of Death LAge If Veteran of U.S.Armed Forces,
'�> February 9L2017
79 War or Dates
ngi. Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens FaUs Hospital
Manner of Death n Undetermined ❑Pending
Q Natural Cause Accident Homicide �]Suicide Circumstances Investigation
.< Title
Medical Certifier Name
ti Stephen Perazzel l
r. Address
100 Park Stree Glens Falls,_NY 12801
District Number Register Number
,,.; Death Certificate Filed 5601
w , City, Town or Village Glens Falls
Date Cemetery or Crematory
liiiEl Burial West Glens Falls Cemetery
`4�- February 15,2017
❑Entombment
, Address
'` ueensbury,NY 12804
>;�Cremation Corinth Rd, Q
Date Place Removed
�'.i ...a Removal • and/or Held
and/or Address
Hold
Date Point of
�'�-
a Transportation Shipment -
by Common Destination
Carrier _
Date Cemetery Address
.A 11 Disinterment
ilt Date Cemetery Address
❑Reinterment
:i _ — Registration Number
^�>% Permit Issued to 01443
Name of Funeral Home Regan,Denny Stafford Funeral Home
f°• Address •
V. 53 Quaker Road ueensbur NY 12804
Name of Funeral Firm Making Disposition or to Whom
:..w: Remains are Shipped, If Other than Above
r' Address
Y%- Permission Is hereby granted to dispose of the human remains described above as indicated.
i
M Date Issued 2/1 3/( 7 _ Registrar of Vital Statistics. r (siy eture)
�;
�f
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z _
1a! Date of Disposition Place of Disposition _ (address)
AU
rt
(section) (lot number) (grave number)
a_ Name of Sexton or Person in Charge of Premises (plea print)
W. Signature J Title
(over)
DOH-1555(02/2004)