Krause, Phyllis NEW YORK STATE DEPARTMENT OF HEALTI-T - - 51
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
PHYLLIS AILEEN KRAUSE F
Date of Death Age If Veteran of U.S. Armed Forces,
01/25/2013 97 War or Dates N/A
#- Place of Death '" . 7 Artiospital, Institution or
City, Town or Village eet AddressIli ELLIS RESIDENTTAT, & RFHARTT,TTATTnN
W Manner of Death❑X Natural Cause El Accident ❑Homicide El Suicide ❑Undetermined El❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
>v GERARDUS JAMESON MD
Address
1238 UNION ST. , SCHENECTADY NY 12308
Death Certificate Filed ,ltrict Number ii , Register Number
City, Town or Village -. 3
❑Burial Date Cemetery or Crematory
❑Entombment 01/28/2013 , PINE VIEW CREMATORIUM
Address -
Ei Cremation QUEENSBURY. NEW YORK
': Date Place Removed
❑
Removal and/or Held
and/or
F,; Address
Hold
O Date Point of
CL El Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
i!Iiii ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home MASON FUNERAL HOME • 01117
Address
18 GEORGE STREET, FORT ANN, NEW YORK 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1.11
Permission is hereby granted to dispose of the human ns d cribed above a indicated.
Date Issued 01/2 6/2 013 Registrar of Vital Statistics
(si nature)
District Number Place
,. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I 19-t3 Place of Disposition 44(itoJ rrweia4a,
2 (address)
Ili
Ul
CC (section) (lot number (grave number)
Name of Sexton or Person i Charge of , emises /.li...._ �toNft
z (please print)
rig Signature L, Title c QCM13tD(L
(over)
•
DOH-1555 (02/2004)