DeVries, Philip Norman I
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
;r Name First Middle Last Sex
Philip Norman DeVries Male
Date of Death Age If Veteran of U.S.Armed Forces,
'' 12/08/2022 62 Years War or Dates
` Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause EAccident E Homicide ESuicide DU ndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
t
• City,Town or Village 5601 613
Burial Date Cemetery,Crematory or Facility Name
'12/14/2022 Pine View Crematory
Entombment Address
'sOLUCremation Queensbury,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
its Hold Address
IL Date Point of
ElTransportatiorr Shipment
by Common
' ' Carrier Destination
Date Cemetery Address
, a❑Disinterment
• Reinterment Date Cemetery Address
dM
,; Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
r Address
r07
Bay Rd,Queensbury,New York 12804
ame of Funeral Firm Making Disposition orto Whom
emains are Shipped,If Other than Above
ddress
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/09/2022 Registrar of Vital Statistics Megan Wolin(ECectronica1Ty Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r 4 iNV � �
Date of Disposition i z l 19 tit Place of Disposition -r,¢ �--
(address)
(section) /�a♦(!ot number) `�� (grave number)
Name of Sexton or Person in Charge of Premises L
(Phase print) �'�,c �,,�
,' Signature f Title � ip
DOH-1555(07/18)p 1 of 2
' r 5r
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#