Blake, Doris 4
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Doris M. Blake Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 1, 2014 96 War or Dates
,,, Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death 1 Natural Cause n Accident n Homicide n Suicide Undetermined n Pending
11 Circumstances Investigation
W: Medical Certifier , Name Title
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Address
G l --/ts 1 r k2
Death Certificate FiledDistrict Number Register Number
City, Town or Village Fort Edward,NY 5755 �L.
XBurial Date Ce.etery or Crematory
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❑Entombment Address i 0
❑Cremation L y) \())--
Date t Place Removed
Z n Removal and/or Held
and/or Address
! Hold
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0 Date Point of
N 1-1Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
11
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is h reb granted to dispose of the human r ' s described bove a indicated.
Date Issued 1 j /tj Registrar of Vital Statistics Y
(signature)
District Number 5755 Place Fort Edward,NY
I certify that the remains{ of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition //!'j`//L,( Place of Disposition 2./ (,.Q.LL 66,r�___ (y (,� , ,y(.{
W ( / (address)
CO —46h( ( 6'� / Z
( ion) (lot number) (grave number)
zName of Sexton or Person in Charge of Premises _I)/U,l9(� (. �Oed�r -*—
(please print)ILI
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Signature JXLLXTitle' R,� (over)
DOH-1555(02/2004)