Blanchard, Dyer s 4
NEW YORK STATE DEPARTMENT OF HEALTH ? ZV
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dyer N. Blanchard Male
=. Date of Death Age If Veteran of U.S. Armed Forces,
March 18, 2017 88 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 94 Feeder Dam Road
10
: Manner of Death I XI Natural Cause I I Accident Homicide Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Ca Robert Evans,MD
Address
Irongate,Glens Falls,NY 12801
Death Certificate Filed District Number Regis4Tumber
City, Town or Village Moreau 4562
❑Burial Date Cemetery or Crematory
March 27, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
N Hold
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d Date Point of
y 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
Address
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Permission is hereby granted to dispose of the human re 4r►s describ ab ve as indicated.
Date Issued 01d0)./7 Registrar of Vital Statistics V
ilee_"( (sig ature)
District Number 4562 Place Moreau ."$ �-&k. ' /Q_`�.S 12-c<
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3)2111? Place of Disposition 'ISM jpiw ( a or)v
2 (address)
W
U)
re
(section) (lot number) (grave number)
p Name of Sexton or Person in Charge of P mises 6 f,14 J
Z g ���(p' ase print)
W
d Title (
Signature "r+f-1/t
(over)
DOH-1555 (02/2004)