DeBlois, Phillip NEW YORK STATE DEPARTMENT OF HEALTF4
Vital Records Section Burial - Transit Permit
r Name First r Middle Last Sex
Phillip Wayne DeBlois Male
W Date of Death Age If Veteran of U.S. Armed Forces,
`.; August 17,2016 61 War or Dates
, Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 63 Connecticut Avenue
Manner of Death Natural Cause n Accident 0 Homicide n Suicide Undetermined Pending
'% Circumstances Investigation
Medical Certifier Name Title
William M.Parker MD
Address
. 100 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village SceS I "'lv
❑Burial Date Cemetery or Crematory
ill Entombment August 24, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E"' Hold
Cl) —
O Date Point of
ri
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 Singleton Sullivan Potter Funeral Home 01596
t
Address
- 407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above
,, Address
s
r Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8 1 t$ 1 a0((, Registrar of Vital Statistics ` Z0Lk --XV.�.,QCcA..
(signature)
District Number S ,S7 Place 0 v c c rS V. 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition l/2�l/j6 Place of Disposition j7,�o (J,��(��/� -4410
W ` (address) /
CO
(section) //��(lot number) (grave number)
p• Name of Sexton or er n i Charge of Premises �(,�.f►�-n c Ga_.�e.- 2_
Z (please print)
W Signature _ Title e 2?v,,iw77i r
(over)
DOH-1555(02/2004)