Phillips Sr., Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
A; Charles M.Phillips Sr Male
a Date of Death Age If Veteran of U.S.Armed Forces,
loki
12/31/2018 87 Years War or Dates Korea
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
: Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
. Circumstances Investigation
s Medical Certifier Name Title
q° Gwendolyn Morris-Dickinson PA
Address
XI
X` 170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
r City, Town or Village Glens Falls
5601 603
,&g ❑Burial Date Cemetery or Crematory
01/03/2019 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
q' Date Point of
,3 Q Transportation Shipment
by Common Destination
Carrier •
n. Date Cemetery Address
• ❑Disinterment
• Reinterment
Date Cemetery Address
• Permit Issued to Registration Number
„--:
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
¢f
Address
53 Quaker Rd,Queensbury,New York 12804
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/03/2019 Registrar of Vital Statistics cg6ertA Curtis(ECectronicaffy Signed)
,$- (signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on:
'11
Date of Disposition i J ij I n Place of Disposition v./ `�AA0r—
(address)
a (section) (lo umber) S (grave number)
0
1, Name of Sexton or Person in Charge of Premises /`s v47
( ease p t)
Signature t Title fFf.nilZ..
(over)
DOH-1555(02/2004)