O'Connor, Philip rims
NEW YORK STATE DEPARTMENT OF HEALTH •
4 S(,c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Philip J. O'Connor Male
Date of Death Age If Veteran of U.S. Armed Forces,
*: July 31, 2015 27 War or Dates
p
•
Place of Death Hospital, Institution or
:1 = City, Town or Village Fort Edward Street Address 41 Mechanic Street Apt 1
Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
. tea
Medical Certifier Name Title
Max Crossman, M.D. Dr.
Address
65 Poultney Steet Whitehall, NY 12887
Death Certificate Filed District Nu Register Tiber
City, Town or Village Fort Edward
�a�
0 Burial Date Cemetery or Crematory
August 4, 2015 Pine View Crematory
-, 0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
-: Date Place Removed
❑ Removal and/or Held
and/or Address `
Hold
Date ! 7 oint of
z�❑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 Broadwa , Fort Edward NY 12828
- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tg Permission is h r y granted to dispose of the huma r ins descri ed a ov,a ndicated.
Date Issued Registrar of Vital Statistics ,
(signature)
District Number 575S Place l(Malt U(.l. CI d
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 08/04/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) A ,(lot number) (grave number)
Name of Sexton or Person in Charge of Premises /4,o Stoat
A ( lease print)
�'` Signature Title ri7.01fk
(over)
DOH-1555 (02/2004)