Monrian111, Philip Frances .tt 1Zei
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Philip Francis Monrian III Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/02/2021 70 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause ID Accident El Homicide Suicide El Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Gwendolyn Morris-Dickinson PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 479
ElBurial Date Cemetery,Crematory or Facility Name
11/02/2021 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
ElDonation
OZ El Removal Date Place Removed
and/or and/or Held
- Hold Address
N
0
4. Date Point of
(I) Transportation
El by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
p— Remains are Shipped,If Other than Above
5 Address
l:
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/02/2021 Registrar of Vital Statistics Ro6ert/7ndrew Curtis(r ?ctronica(Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition 114174 Place of Disposition
2 (address)
W
N
CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pr ises �`` �'�
Z
/p e se print)
W tt
Signature Title (?pt%rw'
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#