Jones, Phillip Lee l 'i'►°1
UNEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Phillip Lee Jones Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/04/2022 65 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 282 White Birch Estates,Moreau Town,New York 12828
Ill
p Manner of Death Ej Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending
0 Circurnstances Investigation
W Medical Certifier Name Title
G Sean Campanie NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 53
EiBurial Date Cemetery,Crematory or Facility Name
10/07/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
- and/or and/or Held
~- Hold Address
W
0
Cl. Date Point of
cJ❑Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Re interment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
N Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/07/2022 Registrar of Vital Statistics Leeann McCabe(Electronically Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this perniton:
I—
WDate
Date of Disposition /U 4Z!/ZZ Place of Disposition Y'1 je L'. evi.) Cr-t ,.40 t-3
2 (adthess/
W
0 CC (section) It number/ (gra re numbed
/
0 Name of Sexton or Person in Chary�e of Premist�Y/�)�' '`� Z
Z (please print)
LIJ
Signature �Lzgi /L// Title (i(-P��-cam
DOH1555(o7/18)ptof2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 7 C
Pine View Cemetery aepresetiting the funeral home named on burial permit
Official Funeral Directors Reg.or License#) r.;,',(