Marvin, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH 4 a
1
Vital Records Section Burial - Transit Permit
"rr: Name First Middle Last Sex
j: Phyllis F. Marvin Female
l:•
:r? Date of Death Age If Veteran of U.S. Armed Forces,
April 29, 2014 85 War or Dates
rj Place of Death Hospital, Institution or
City, Town or Village Schuylerville Street Address Stanton Nursing & Rehab Centre
01, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
til Circumstances Investigation
Medical Certifier Name Title
Suzanne Blood Dr.
Address
' Manor Drive,Queensbury,NY 12804
;rr Death Certificate Filed District Number Register Number
:.:_r City, Town or Village Queensbury -joi N
❑Burial Date Cemetery or Crematory
April 30,2014 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
U) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:::i: Permit Issued to Registration Number
▪:r Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
Address
tg
Permission is hereby granted to dispose of the human rem ' descri a ove,.as indicated.
▪:•: Date Issued ^t 3b 1)I Registrar of Vital Statistics
signature
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 6-j11iq Place of Disposition ,�1w.✓ (, #trl-'0-
W (address)
U)
tY (section) .(lot numbery- (grave number)
pName of Sexton or Person in Charge of Premises ,j- _ t4,
'Z ll de,....
/ease print)
Signature ..4Title _ �.`(, .
(over)
DOH-1555(02/2004)