Phillips, Norman NEW YORK STATE DEPARTMENT OF HEALTH 6-"c4s
Vital Records Section f Burial - Transit Permit
Name First Middle Last Sex
Norman D Phillips Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 7, 2011 43 War or Dates
, Place of Death Hospital, Institution or
M , City, Town or Village Glens Falls Street Address 29 Madison Street Apt B
a Manner of Death I XI Natural Cause Accident I I Homicide 1 Suicide Undetermined Pending
lf- Circumstances Investigation
a,. Medical Certifier Name Title
13 Robert Sponzo,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Regis er tber
' City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑Entombment October 11, 2011 Pine View Crematory
Address
�x Cremation Queensbury,NY
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
a.
co Transportation Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
_' 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
,E, Address
ILI
' ' Permission is hereby granted to dispose of the human remains described abov as i is ted.
Date Issued /0/p7 20// Registrar of Vital Statistics
(signature)
: District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition lu lot It( Place of Disposition s Vim, 6 ri,,r,
W (address)
N
re
O (section) dt,slili-,r
(lot numbe (grave number)
inName of Sexton or Person in Charge of Premises ey
Zgill, (please print)
Ili
Signature ..,/ Title atr�Im Q
(over)
DOH-1555(02/2004)