Phillips, Jerry NEW YORK STATE DEPARTMENT OF HEALTH w , 1 SSA
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jerry Harold Phillips Male
Date of Death Age If Veteran of U.S. Armed Forces,
_> July 22, 2015 62 War or Dates ii
Place of Death Hospital, Institution or
C"' City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death 0 Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Us Circumstances Investigation
W Medical Certifier Name Title
a Suzanne M. Rayeski, M.D
Address
170 Warren Street Glens Falls, NY 12801
• Death Certificate Filed District Number ) Register Number
City, Town or Village CIJ
s ., ❑Burial Date Cemetery or Crematory
July 28, 2015 Pine View Crematorium
= ❑Entombment Address
'MCremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑
Removal and/or Held
and/or Address
E Hold
co Date Point of
a. ❑Transportation Shipment
CO by Common Destination
CI Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
• ' Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iC;
W
O. Permission is hereby gr nted to dispose of the human remains des abed bo a ated.
Date Issued 0 7 25f 28fj— Registrar of Vital Statistics � '
(signature)
• District Number S`$0/ Place �a� /la, !Uy`
I certify that the remains of the decedent identified above(y.,1J[ere disposed of in accordance with this permit on:
£{n Date of Disposition 07/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2; (address)
w
to
ce (section) (lot` number) (grave number)
0 Name of Sexton or Person in Char of Premises is t11 C) — 7 b.�rui-v e
�Z ����'"-'4. (please print)
Signature �•,. Title �rc�►.�}�rf PI'S f;
(over)
DOH-1555 (02/2004)