Blanchard, Richard y
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Middle Last Sex
Richard A. Blanchard Male
,, Date of Death Age If Veteran of U.S. Armed Forces,
V' January 8, 2017 69 War or Dates Vietnam
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
,f Manner of Death n Natural Cause n Accident n Homicide n Suicide 0 Undetermined ri Pending
s.
Circumstances Investigation
ni, Medical Certifier Name Title
..„.. i2 OdneA q ‘r3NO
. Address 5 p� �Y 1 l.0 ) c,_ 3 aAv ci gP o n t�v S,
• Death Certificate Filed District Number Register Number
City, Town or Village Saratoga 4501
®Burial Date Cemetery or Crematory
❑Entombment January 12, 2017 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
f' Hold
N
0 Date Point of
N0 Transportation Shipment
p by Common Destination
Carrier
Li Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
<fi Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
41, Name of Funeral Firm Making Disposition or to Whom
«, Remains are Shipped, If Other than Above
r=`' Address
;t
•: Permission is hereby granted to dispose of the human remain 'b about):
' dicated.
Date Issued I )(� I1/1 1-} Registrar of Vital Statistics e -
r••
(signature)
14
District Number 4501 Place Saratoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
iii Date of Disposition 1 /1 2/1 7 Place of Disposition Pine View Cemetery, Queensbury, NY
ill (address)
N Erie 25C 1
ZCe (section) (lot number) (grave number)
Name of Sexton or Person ' Charge of remises ('onn i P L_ Goeder t-
(please print)
W Signature t-it .24,Le.,, 1 Title Cemetery Superintendent
(over)
DOH-1555(02/2004)