Russell, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH ' '.'`
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phyllis Russell Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 9, 2016 78 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined IT Pending
Circumstances Investigation
W Medical Certifier Name Title
Philip J. Gara, Dr.
Address
318 Broadway Fort Edward 12828
Death Certificate Filed District Number Registey Number
City, Town or Village Fort Edward 75 l
❑Burial Date Cemetery or Crematory
February 10, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
8 and/or Address
Hold
Date Point of
t�l. 0 Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
A. Permission is he eby /ranted to dispose of the human . s described e as i icated.
Date Issue q /(O Registrar of Vital Statistic o0
signature)
District Number 7 Place /Ay-, /4 zt
6. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I Date of Disposition 02/10/2016 Place of Disposition Quaker Road Queensbury,NY 12804 Qtr+r,0r, Gre,,o tcrY
(address)
VI
(section) (lot number) (grave number)
IName of Sexton or Person in Charge of Premises Taime.)Y 5C(1,0)r'e_,S
(please print)
W Signature`s/ h, Title C-'re,A':1}or
G
(over)
DOH-1555 (02/2004)