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Blackburn, Loren NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Loren H.Blackburn Male Date of Death Age If Veteran of U.S.Armed Forces, 06/16/2017 88 Years War or Dates 1947-1950 li Place of Death Hospital, Institution or , City,Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending Circumstances Investigation Medical Certifier Name Title Farhana Kama! MD 1 Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 333 '`®Burial Date Cemetery or Crematory 06/21/2017 St.Aiphonsus Cemetery ❑Entombment Address ❑Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of .❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address 1:1❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom e Remains are Shipped, If Other than Above Address 4 Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/19/2017 Registrar of Vital Statistics 4t96ertACurus Ekaronica/TyAped- (signature) . District Number 5601 Place Glens Falls, New York I certify that the remains of t e decedent identified above were disposed of in accordan with this permit on: Date of Disposition (1 ,f i l I Place of Disposition S - 4/ L1JLl ke,(faddr Z '`G (section) 114fri (lotnumbe►) (grave number) Name of Sexton or Person in Charge of Premises Ifit / (please print) Signature `�---' Title (over) DOH-1555(02/2004)