Perry, Philip ! tt 3 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First - Middle Last Sex
Philip Henry Perry Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/04/20/2 77 years War or Dates
o eat Hospital, Institution or
City,'To V I ..-Ct Street Address
�.� X Glens Fa ClcnsElibhNteggniedanner of Deat `►il Natural Cause LI Accident Homicide Suicide Pending
Circumstances Investigation
tg Medical Certifier Name Title
II
Address Hoffman M. D.
100 Park Street Glens Falls, NY 12801
gq D th Certificate Filed District Number Register Number
Cit , ToCS�XVCX Glens Falls 5601 •
319
Burial ate Cemetery or Crematory
❑Entombment 07/06/2012 Pine View Crematory
Address
!iiig5r9remation Queensbury, NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
h Hold
t
0 Date Point of
CI i—i
0 Li Transportation Shipment
Cl by Common Destination
Carrier
El Disinterment Date Cemetery Address
;iigQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 I afayette Street Oiieenshury, N Y 12804
iil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tU
` Permission is hereby granted to dispose of the human remains described above as indicated.
iiiT Date Issued 07/06/2012 Registrar of Vital Statistics !A)
Q LA.)
signatur
District Number Place `,I
5601 Glens Falls //l/ ����
.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k.
iU Date of Disposition 1.1_i? Place of Disposition K V,4M, Ciw-c f on.,
1 (address)
U,
CC (section) 4 (lot number) (grave number)
Name of Sexton or Pers n in Charge o Premises ihrot pleaseprint)
Z I
14
Signature Title Olen P-ro'.
(over)
DOH-1555 (02/2004)