Blackbird, Alma d I. i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
`__ Name First Middle ' Last Sex
Alma Blackbird female
Date of Death Age If Veteran of U.S. Armed Forces,
05/15/2006 86 War or Dates n/a
14 Place of Death Hospital, Institution or
Z City, T� 6X Moicja Glens Falls Street Address 14 Staple Street
lika Manner of Death rviuli Natural Cause ID Accident 0 Homicide D Suicide El Undetermined ri Pending
Circumstances LI Investigation
W Medical Certifier Name Title
Thomas B. Coppens, MD
Address
3 I&ngate Centre, Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, 305305XI X X Glens Falls 5601 2 2.)
❑Burial Date Cemetery or Crematory
05/15/2006 y �,
❑Entombment PinAddress
.®Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
42❑and/or Address
t: Hold
0 Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier '
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to k Registration Number
Name of Funeral Home Regan & .Denny Funeral Home 01519
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
Q
W
a" Permission is hereby granted to dispose of the human remains described above as i ated.
Date Issued 3/)51 0 Registrar of Vital Statistics /4iY,:t, X2?-
(signature)
District Number 5 6 0 ( Place 6 5 V.a, l `s) KJ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f ,
2
ILI Date of Disposition S Ai/t Place of Disposition F i nr,,,r... rz.e w,c tc ~J
(address)
tLi
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises C h rt s .;c' ,,h ir
(please print)
>: Signature 1. -I Title r6.---L Or
(over)
DOH-1555 (02/2004)