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Blake, Carl NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section ini Name First Middle Last Sex Carl 0. Blake male Date of Death Age If Veteran of U.S.Armed Forces, Miii December 25, 1991 78 War or Dates yes WW II Place of Death Hospital, Institution or w City,Town or Village City of Glens Falls Street Address Glens Falls Hospital ©..Manner of Death ......... Undetermined Pending W ® Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ ❑ Circumstances Investigation W Medical Certifier Name Title ,) Robert Evans MD Address 3 Irongate Center, Glens Falls New York 12801 Death Certificate Filed District Number Register Number � D' City,Town or Village City of Glens Falls � / Tel? Date Cemetery or Crematory In Burial December 28, 1991 Pine View Cemetery ❑Cremation Address Queensbury, New York 2 Date Place Removed O. 0 Removal and/or Held 1 and/or Hold .::::.....................:..:.::.... .:.....: Address N cL Date Point of cn 0 Transportation by Shipment p Common Carrier Destination ................................................................................................................................................................................... ..................................................................................... El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firm Regan and Denny Funeral Service, Inc. 01602 ................................................................................................................................................................................................................................................................................... Address 26 Quaker Road, Queensbury, New York 12804 .................................................................................................................................................................................................................................................................................... Name of Funeral Firm Making Disposition or to Whom j' Remains are Shipped, If Other than Above Address ' igg Permission is hereby granted to dispose of the human re ins described above as indicated. Date Issued ,}. / Registrar of Vital Statistics _fr.,C AtiAta Ai- (signature) iM District Number. 0 / Place //" "--r '"�"`�^ G �'L I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t- Date of Disposition -g,. ' `— ' r 1 • po /�e�-.� 1,�" 7 Place of Disposition �� fj -c.,, �r ,L. f=is �l7 � -y s'F�;� y' j /�t 2 / tu } (address) // rn IX (section) (lot number) (grave number) p•- Name of Se o Person in Charge of Premises f)-- -,ice./L= �� s. lT�; Z nn (please print) W Signature ` a"l.Lt� . f ? -� Title . DOH-1555 (10/89) p. 1 of 2 VS-61