Blake, Matthew NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Matthew Robert Blake Male
Date of Death Age If Veteran of U.S.Armed Forces,
January 24, 2012 4 War or Dates No
ZPlace of Death Hospital, Institution
LJJ City ,Town or Village City of Albany or Street Address Albany Medical Center
p Manner of Death Natural ❑ Undetermined ❑ Pending
v' ® Cause ❑ ❑Accident Homicide ❑ Suicide Circumstances Investigation
0 Medical Certifier Name Title
0 Rishi Ram Adhikari MD
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 172
Date Cemetery or Crematory
® Burial January 30, 2012 Pine View Cemetery
❑ Entombment Address
❑ Cremation
Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q' ❑ and/or Address
Hold
7'
Transportation Date Point of
CL Shipment
❑ By Common p Carrier Destination
'
❑ Disinterment
Date Cemetery Address
❑ Date Cemetery Address
Renterment
Permit Issued To Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
68 Main Street, Hudson Falls, NY 12839
H
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g' Address
W
a. Permission is hereby granted to dispose of the human remains described abo as indicated. '�A)
Date January 25, 2012 Registrar of Vital Statistics Cz / t
Issued (s!gnat re)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z; Date of Disposition 1 /30/1 2 Place of Disposition Pine View CPmPtery
w (address)
w Erie 55E 1
U)
Ce (section) (lot number) (grave number)
0
0'
w` Name of Sexton or Person in Charge of Premises Michael Genier
(please print)
Signature � '�a� f/vw�'� Title Superintendent
(over)
DOH-1555 (02/2004)