Blake, Deanie *17
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Deanie Blake Male
Date of Death I Age If Veteran of U.S. Armed Forces,
Dec. 30, 2017 j 55 yrs. War or Dates no
.i.4 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ltil
iti Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide E Undetermined ❑Pending
Circumstances Investigation
1§ Medical Certifier Name Title
Michael Sikirica MD.
A1isMedical Ctr.
New Scotland Ave. , Alnany, NY.
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 Qri
Date Cemetery or Crematory
❑Burial Jan. 04, 2018 PineView Crematorium
Address
E Cremation Queensbury, NY. 1 2804
Date Place Removed
0 ❑I—I Removal and/or Held
-- and/or Address
li Hold
Q Date Point of
0' Transportation p ortation
Shipment
a by Common Destination
Carrier
Date Cemetery Address .
El Disinterment
❑ Reinterment Date Cemetery Address
gil Permit Issued to Registration Number
in Name of Funeral Home Mason Funeral Home 01117
Address
18 George St. , P.O. Pox 277, Ft. Ann, NY. 12827
i.``, Name of Funeral Firm Making Disposition or to Whom
L.4..14 Remains are Shipped, If Other than Above
::a Address
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
miii
Date Issued Jan. 04, 201 8 Registrar of Vital Statistics W CA,Cy,---k.k-,,J.Jw
(signature)
District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance�with this permit on:
W Date of Disposition /S'�)'3 Place of Disposition .U- e.i c,
2 (address)
UJ
C (section) lot number} (grave number)
QName of Sexton or Person in Charge of Premises r,, • �.;.,y {
(please print)
Signature �� ---i Title /0/01111/1.,
(over)
DOH-1555 (9/98)