Philips, John -` 475.
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Trans t Permit
•: Name First Middle Last Sex
John Philips Male
;ff Date of Death Age If Veteran of U.S. Armed Forces,
j; October 16, 2015 61 War or Dates
'�'�:: Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 5 Brown Paths
?i Manner of Death X Natural Cause Accident 1 I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Eric Pillemer M.D.
*f: Address
:r ; 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Registgr Number
;:; City, Town or Village 5cp 5 q 1 lIli
❑Burial Date Cemetery or Crematory
❑Entombment October 16, 2015 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:;:; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
i.:, 53 Quaker Road, Queensbury, NY 12804
,.. : Name of Funeral Firm Making Disposition or to Whom
rr' Remains are Shipped, If Other than Above
Address
::::r Permission is hereby g dispose to dis ose of the human remains described above as indicated.
'r•:::: 1 ,n , '
Date Issued 10' !I �15 Registrar of Vital Statistics `- . r( "t- _
(signature)
.•. District Number 3.1 j7 Place V�c,-NS I, w Al
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z w Date of Disposition 10l flf fs i.Place of Disposition • ifi.s ai—cfos„.--
2 (address)
W
CO
CL (section) l (lot number) (grave number)
a Name of Sexton or Person in Char a of Premises
Z �h r 03 lease print)
W
Signature Title O/
(over)
DOH-1555(02/2004)