Brown, Philip z
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Philip Jason Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 7,2013 101 I War or Dates
F. Place of Death Hospital, Institution or
11Z City, Town or Village Bolton Street Address 253 Federal Hill Rd.
0 Manner of Death g Natural Cause Accident Homicide Suicide Undetermined " Pending
tu Circumstances Investigation
w Medical Certifier Name Title
0 Dr.William Borgos
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed I District Number Register Number
City, Town or Village Bolton 5650
❑Burial Date Cemetery or Crematory
El Entombment January 9,2013 j Pine View Crematory
Address
Ex Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal I and/or Held
and/or Address
F Hold
N
0 Date Point of
a Transportation Shipment
a by Common Destination
Carrier
I
Disinterment Date Cemetery Address
Reinterment Date 1 Cemetery Address
1
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
E Address
re
w
0-
Permission is hereby granted to dispose of the human r ain described ab,eXe s indicat d.
Date Issued / D Registrar of Vital Statistics j�( ,i /L
(signature)
District Number 5650 Place Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition 1-11-13 Place of Disposition . t` CND' �-�4y
W (address)
N
CL
(section) (lot tuber) - st Jaye number)
pName of Sexton or Person in Charge of Premises Aft
Z r (please pri t)
ILI
V.Signature Title ((Q( „'T"'—>
(over)
DOH-1555 (02/2004)