Staats, Philip William //Th
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Philip William Staats Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/06/2022 71 Years War or Dates 1970-1972
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pendin
11.1
El Natural Cause Accident Homicide Suicide g
Circumstances Investigation
Medical Certifier Name Title
0 Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 611
Burial Date Cemetery,Crematory or Facility Name
12/09/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
tl Date Point of
(/)❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment 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
j— Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/08/2022 Registrar of Vital Statistics Megan Wolin(ECectronicalTy 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:
Z Date of Disposition Mil I ZZ Place of Disposition
2 (address)
W
CC (section) A (lot number)< (grave number)
Name of Sexton or Person in Charge of miles
z (p14.jise print)
LLI Signature Title 1<�tntj IT'S
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 6 e5
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#