Monroe, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH v +s q 01,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phyllis E. Monroe Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 30,2011 63 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Aged A.Gillani MD
Address
102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
Entombment September 1,2011 Pine View Crematory
Address
❑X Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
co
O Date Point of
u) Transportation Shipment
a 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
F- Remains are Shipped, If Other than Above
E Address
tr
a Permission is hereby granted to dispose of the human remains described above as indicted.
Date Issued 09-01-11 Registrar of Vital Statistics CA_ 4r l�
(signature)
District Number 5601 Place Glens Falls,NY
t-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uu Date of Disposition K I L K( Place of Disposition 9,gtIt,j Cr'v.4ird,,.,
(address)
N
(section) a (l t number) (grave number)
el• Name of Sexton or P on in Charge �f Premises osk
W f ` ( lease print)
&-
L ` Title Ct1 Signature L �, C,.'[c�
(over)
DOH-1555 (02/2004)