Phillips, Raymond NEW YORK STATE DEPARTMENT OF HEALTHIII # <13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Edward Phillips Male
< Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2014 85 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley
Manner of Death nri
ifi Natural Cause ❑ Accident E Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
200 Main Street Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Argyle 6'75i, (y
❑Burial Date Cemetery or Crematory
February 18, 2014 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
. ❑ Removal and/or Held
and/or Address
Hold
' Date Point of
cL. ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
jk t.
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01077
Address
123 Main St., Argyle NY 12809
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4,,, Ay Registrar of Vital Statistics S,,tie_ety m(Jjitl, —
„ (signature)
District Number �7 �(.) Place A (2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/18/2014 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /j(lot number) (grave number)
Name of Sexton or Pers n in Ch rge of Premises t+4 P"^!1
(pl ase print)
' Signature yL Title caini
(over)
DOH-1555 (02/2004)