Phillips, Larry NEW YORK STATE DEPARTMENT OF HEALTHL
Vital Records Section Burial - Transit Permit
e= Name First Middle Last Sex
Larry L. Phillips Male
Date of Death Age If Veteran of U.S. Armed Forces,
: November 15, 2012 62 War or Dates
We .o Place of Death Hospital, Institution or
. City, Town or Village Glens Falls Street Address Glens Falls Hospital
c Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
C' Circumstances Investigation
us Medical Certifier Name Title
• John Stoutenberg,MD
Address
Glens Falls,NY
Death Certificate Filed ' District Number Register Number
:' City, Town or Village Glens Falls,NY 5601 52,`i
❑Burial Date Cemetery or Crematory
II Entombment November 20, 2012 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O Date Point of
O.
• Transportation Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:i 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
E: Address
Q.
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ) /161 ( Z Registrar of Vital Statistics (AD CAwVrRr W
(signature)
'- District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance��** with this permit on:
WDate of Disposition it /2i/jZ Place of Disposition Piat). ..1 ( " , ar,,,...
2 (address
W
N
CC (section) - (lot limber) (grave number)
QName of Sexton or Person in Charge f Premises 40 if r ,.)t 4.4tr
Z (please print)
W
Signaturedill--
Title CRmftT0t
(over)
DOH-1555(02/2004)