Powers, Phillip k'k S_,
4
NEW YORK STATE DEPARTMENT OF Burial Records Section _ Burial - Transit Permit
Name First Middlee Last Sex
Phillip =ul Powers Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/05/2018 68 years War or Dates
1 Place of Death Hospital, Institution or
City, Tcxxxxr jotinx Glens Falls Street Address Glens Falls Hospital
a Manner of Death LtdNatural Cause 0 Accident 0 Homicide El Suicide riUndetermined Pending
Circumstances Investigation
U.
iti Medical Certifier Name Title
Philip J. Gara. Jr M. D.
Address
327 Broad y Fort Edward, N y 12828
liiiii Death Certificate Filed D trict Number Register Number
iMi City, TXXXXr MONK Glens Falls 5601 13
DBurial Date C_ metery or Crematory
dill El Entombment 01/12/2018 . Pine View Cematory
Address
(Cremation Queensbury, Ny
Date Place Removed
Removal and/or Held
a
�;; Address
inand/orHold
C Date Point of
CL
Q Transportation Shipment
ct by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
,;.• Remains are Shipped, If Other than Above
u Address
ir
Ili
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/09/2018 Registrar of Vital Statistics )G k (A n,jature)
District Number iiii 5601 Place Glens Falls a y
:;::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1
2 � V--...1
fit Date of Disposition I/M�Mil Place of Disposition 'Tint a r
2 (address)
VI
+ )
CC (section) dot number) (grave number)
Name of Sexton or Person in Charge of Pr mises C ., �w44/171-
(plea a print)
Signature Title 'itVir -
(over)
DOH-1555 (02/2004)