Farley, Phyllis joan • F.)NEW YORKSTATE DEPARTMENT OF HEALTH `` ._,. Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Phyllis Joan Farley Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/29/2022 74 Years War or Dates
Place of Death Hospital,Institution or
Z-
City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Joshua Started NP
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 70
Burial Date Cemetery,Crematory or Facility Name
12/02/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
DDonation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0 -
Transportation Date Point of
0 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/02/2022 Registrar of Vital Statistics Jenny Linia M Matteffe(Efectronica1Ty Signed)
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition /2-3--2',Z Z Place of Disposition A e
2 (address)
W
NCC (section) (lot numb%) i (grave number)
Name of Sexton or Person in Charg f Premises � � ', t.00/)ct
(please print)
W Signature � , �(� Title
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#