Blair, Fay L. 790
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Fay L.Blair Female
Date of Death Age If Veteran of U.S.Armed Forces,
". 11/26/2019 80 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village WarrensburgTown Street Address 766 Schroon River Road,Warrensburg Town,New York 12885
in W Manner of Death
®Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Umbreen Rozell MD
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Warrensburg 5660 19
Date Cemetery,Crematory or Facility Name
Burial
11/27/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
Hold Address
aDate Point of
) ❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2019 Registrar of Vital Statistics DonnaACom6s(ECectronicallySiyned)
(signature)
District Number 5660 Place Warrensburg, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition nIZ111 Place of Disposition 4-Tet•wfi.-
(address)
W
N (section) (lot number) (grave number)
Name of Sexton or Person in Char of Premises
z f ase print/
W' Signature [� r Title
DO H-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 11.31-15
Receipt
Human remains of ` ,' delivered on , 20
Pine View Cemetery Repiegenting the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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