Phillips, Kenneth •
NEW YORK STATE DEPARTMENT OF HEALTH.... ( b
Vital Records Section • Burial,. Transit Permit
Name First K
Mid ,L lorces,
S Sex
inn {'1
Date of.Deat Age ,; #Veteran of U.fasJ )
rmed
—): .n� ,1. r adoi7 /5 , ,.War or Dates 40
} of Death Hospital, Institution or
':1 own or Village CLL'n5- 11.S" Street Address v s 11
1t 'anner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
to Circumstances Investigation
iti Medical Certifier Nam Ii� Title
('L- 64.oi�T1 - Cr -,bhy M -
Address , •
»> t3e Certificate Filed District Number Register Number
LCi own or Village ' a L({" Sa(
ill['Burial Date / ` :7 Cemetery or Crematory '
( aoi
<' Entombment .. r�� `�U C�c r„- r
Address ( v
:.g DCremation
Date' J Place Removed
Removal and/or Held
fl and/or Address
Hold
0 Date Point of
Q Transportation . Shipment
4 by Common Destination
Carrier .
0 Disinterment Date Cemetery Address
''' 0 Reinterment i Date Cemetery Address
Permit Issued to Registration Numb r
Name of Funeral Home .cDF- II'' G 0 47447
. ril!..1 Address -
er "-- 4-v e ,r^•.d.L- )J 7 /'a g d)..._
Lik Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
. Address •
-
rt Permission is hereby granted to dispose of the human remains descri d above s in ed.
<>'> Date Issued C ,/�- //7 Registrar of Vital Statistics '"/_t
'''`iiiiii (signature)
E'' District Number S^6 0/ Place 6 4an -1-A 1 f,.f''
iii,,i; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition 61 LI C) Place of Disposition iNc•t,),.v Crbrn7`tcrs
(address)
01
re (section) (lot number) / rave number)
CIName of Sexton or Person in Charge of P mises c /,c, i"i+01z114
2 (please print)
1 Signature v` Title t.
(over)
•
DOH-1555 (02/2004)