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Phillips, Rachael NEW YORK STATE DEPARTMENT OF HEALTH ft Z 63 Vital Records Section Burial - Transit Permit i Name First Middle Last Sex Rachael M. Phillips Female Date of Death Age If Veteran of U.S. Armed Forces, May 20, 2011 43 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause 0 Accident El Homicide n Suicide El Undetermined 0 Pending Circumstances Investigation Medical Certifier Name Title Carnal Khalifa, Dr. Address 100 Park Street Glens Falls 12801 Death Certificate Filed District Number �� 1 Register Number City, Town or Village S2. 4 0 0 Burial Date Cemetery or Crematory May 23, 2011 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 71 Removal and/or Held and/or Address Hold Date Point of 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 01097 N Address 136 Main Street, South Glens Falls NY 12803 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. f Registrar of Vital Statistics (�3 �.7 F} Date Issued � /7.0� 1 C�'�`-�1�- (signature) District Number 560) Place 6 LinpS \\S, 0 9 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: mot Date of Disposition 05/23/2011 Place of Disposition Quaker Road Queensbury,NY 12804 (address) i (section) . (lot num er) (grave number) eT I Name of Sexton or P r on in Charge f Premises c%5 .�o r4�tlf (please print) Signature Title CeErhAIeC (over) DOH-1555 (02/2004)