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Carpenter, Philip 1 t . . .) # " 1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Philip Nelson Carpenter Male Date of Death Age If Veteran of U.S. Armed Forces, October 24, 2013 71 War or Dates p— Place of Death Hospital, Institution or W City, Town or Village of Granville Street Address Indian River Health Care Facility p Manner of Death©Natural Cause Accident E Homicide 0 Suicide Undetermined Pending Circumstances Investigation lit Medical Certifier Name Title p Susan Sperry NP Address 17 Madison Street, Granville, NY 12832 Death Certificate Filed of Granville District Number Register Number City, Town or Village 5725 41 =0 Burial Date Cemetery or Crematory October 28, 2013 Pine View Crematory ❑Entombment Address ®Cremation Queensbury, NY Date Place Removed Z Removal and/or Held 2❑and/or Address Hold In Date Point of IL ❑Transportation Shipment is by Common Destination Carrier a, Disinterment Date Cemetery Address E Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home 01079 Address zt 82 Broadway, Fort Edward, NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address tL ELPermission is hereby granted to dispose of the human remain e ri d s indicated. Date Issued October 25,2013 Registrar of Vital Statistics A. (signature) District Number 5725 Place Village of Granville F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z l:LJ Date of Disposition 1c/3oh13 Place of Disposition C� �.� ..) fre%floe ti,,, 22 (address) W U rt (section) �(lot�nu ber) t`' (grave number) Q tr Name of Sexton or Person in Charge o .Premises ! "'"J t" r '''K Z (plea print) W Signature lit. , Title til/PiltD t (over) DOH-1555 (02/2004)