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Phillips, Mark
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Mark David Phillips Middle Last Sex Date of Death Age If Veteran of U.S. Armed Forces, Male 10/26/2019 53Years War or Dates F— WCity, Place of Death Town or Village Hospital, Institution or al Manner of Death Glens Falls N Natural Cause © Accident Street Address Homicide Glens Falls Hospital U Suicide Undetermined Pending nW Medical Certifier Name Circumstances Investigation Matthew Loftus TitlePA Address aua, rvt: TOfK 1ZtSUl Certificate Filed District Number own or Villa a Register Number g Glens Falls 5601 [Fell-••• 464 rial Date Cemetery, Crematory or Facility Name 10/28/2019 Pine View Crematory tombment Address _ Cremation Queensbury, New York Donation ZO ❑ Removal Date Place Removed P and/or and/or Held N Hold Address O a to Date Point of Transportation r0 by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to /� Registration Number Name of Funeral Homc M B Kilmer F neral Home - Fort Edward 01079 Address 82 Broadway, Fort Edward, New York 12828 Name of Funeral Firm Making Disposition or to Whom F-. Remains are Shipped, If Other than Above Address Lu a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/28/2019 Registrar of Vital Statistics RQ6ertAndrew Curtis (ECectronicaCCy Signed) (signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition p Place of Disposition 2L r ... 2 (address) W X(section/ /lot number/ (gravenumber) 0 Name of Sexton or Person i Charge of Premises Z lease print/ Lu Signature Title A� DOH-issS (07A8) c 1 of 2 Public Health Law Sec. 4145(2b) V - �--- Receipt v � i-0 20 Human remains of �N delivered on Pine View Cemetery Official Representing the funeral home named on Funeral Directors Reg. or License # / ff