Jacobs, Phyllis Ci
NEW YORK STATE DEPARTMENT OF HEALTH V '►Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phyllis A. Jacobs Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 24,2011 75 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 12 Ashe Drive
Wp Manner of Death X Natural Cause J 'Accident Homicide Suicide Undetermined Pending
tll Circumstances Investigation
to Medical Certifier Name Title
0 Dr.John Rugge
Address
HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
Entombment February 25,2011 Pine View Crematory
Address
®Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
H Hold
Cl) -
O Date Point of
O. Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the hum remai escribe bove as indicated.
Date Issued k-S�// Registrar of Vital Stati ics
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
W Date of Disposition z-7 -u Place of Disposition ('�n: U k,+•.� C..itl►;}vr,�r..
W (address)
N
(section) (lot nu r) (grave number)
pName of Sexton or Person in Charge f Premises n hc,stopkir Jenfir
W �fp ! (please print)
Signature Title C2¢`A Ik i uR
(over)
DOH-1555 (02/2004)