Blake, Philip NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Philip E. Blake Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 29, 2017 86 War or Dates
}- Place of Death Hospital, Institution or
Z; City, Town or Village Glens Falls Street Address Glens Falls Hospital
0' Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
11.1 Circumstances Investigation
G Medical Certifier Name Title
Susanne Rayeski
Address
100 Park Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 ,3 0
❑Burial Date Cemetery or Crematory
June 2, 2017 Pine View Crematory
El Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
0.
L) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls, NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
Ui
L.
Permission is hereby granted to dispose of the human remains describedA above as indicated.
Date Issued 6` 24/7 Registrar of Vital Statistics .j3 Ci4�" . Q r Lk..)
(signature
ff
District Number 5601 Place Glens Falls IV y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z a.
w Date of Disposition cis IQ Place of Disposition 'F�?Y,,,, ( or;
W (address)
N
0 (section) /%(lot number)e ofSexton orPerson �- (grave number)
ZNam in Charge of Premises hr,, �.4— 04'111r
W (pl ase print)
Signature L� / Title ji1iEim11 1..
(over)
DOH-1555 (02/2004)