Bleickhardt, Carol NEW YORK STATE DEPARTMENT OF HEALTH 1 g
Vital Records Section Burial - Transit Permit
I Name First Middle
Last I Sex
Carol D. Bleickhardt I Female
Date of Death i Age I If Veteran of U.S. Armed Forces,
01/27/2017 j 88 1 War or Dates
Wt""I Place of Death I Hospital, Institution or
City, Town or Village Glens Falls ! Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑ Accident ❑Homicide Suicide � Undetermined Pending
Circumstances Investigation
1W f Medical Certifier Name Title
a Kasandra Frasier, MD,
Address
9 Carey Road Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village ,.5.- 0� S-
1 ❑Burial Date I Cemetery or Crematory
❑Entombment 01/30/2017
Address
®Cremation
Date Place Removed
z ❑ Removal and/or Held
and/or Address
F. Hold
a0 Date Point of
` Transportation Shipment
_ by Common Destination
0` Carrier
L Disinterment Date Cemetery Address
EiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ) 3 L� ) I ) Registrar of Vital Statistics , A ... U6, /�-te
(signature)
District Number 5 6 I Place G' S f�;I '
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W; Date of Disposition 1131 113 Place of Disposition 1 c JP_ C{prowl f 1.."—•.
W' (address)
CO
f (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises §i4; �a 4�l (T
W (pie se print)
Signature �� LF Title (RE MAPIL
(over)
DOH-1555 (02/2004)