Blake, Richard NEW YORK STATE DEPARTMENT OF HEALTH : . + LI u
Vital Records Section 3 Burial - Transit Permit
t
Name First Middle Last Sex
Richard Sewell Blake Male
Date of Death Age If Veteran of U.S. Armed Forces,
I- November 9, 2006 70 War or Dates
2 Place of Death Hospital, Institution or
W City, Town, or Village Glens Falls Street AddressGlens Falls Hospital
G Manner of Death x❑ Natural Cause ❑ Accident ❑ Homicide Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
J Medical Certifier Name Title
W CHARLES LOWE_MD
0 Address
611 Glen Street ,
RDeath Certificate Filed Distrid Number Register Number
City, Town or Village Glens Falls t'Q,0/ ,5 57
Date Cemetery or Crematory
❑ Burial November 13, 2006 Pine View Crematorium •
Address
❑X Cremation Ouaker Road Oueensburv, NY 12804-
Date Place Removed
0 ❑ Removal and/or Held
- and/or Address
Hold
0 Date Point of
0 ❑Transportation Shipment
C. by Common Destination
A Carrier
Li Date Cemetery Address
o ❑ Disinterment
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00283
Address
F 68 Main St., P. O. Box 67, Hudson Falls, New York 12839
Name of Funeral Firm Making Disposition or to Whom
x Remains are Shipped, If Other than Above
w Address
O.
Permission is her by ranted to dispose of the human remai described abo as indica d.
Date Issued Registrar of Vital Statistics -Z..2Z-ems
(si ature)
District Number 5ied Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�
W Date of Disposition 1I /N/(,(, Place of Disposition Ping\i+ew Ct�,4--i-ot•. ..
2 (address)
W
h
it (section) (lot number) (grave number)
0
O Name of Sexton or Perso in Charge of Premises Cl.c,s Su.vne tf
W 2j; (please print)
Signature L AU.4 Title C ,,t}vt'