Blair, June Beverly NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
June Beverly Blair Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/11/2020 87 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
W Natural Cause Accident Homicide Suicide g
Circumstances Investigation
WMedical Certifier Name Title
Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 124
❑Burial Date Cemetery,Crematory or Facility Name
03/16/2020 Pine View Crematory
Entombment Address
c❑Cremation Queensbury Town, New York
❑Donation
OZ Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a Transportation Date Point of
fp �
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
11 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Other than Above i
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/16/2020 Registrar of Vital Statistics JWert-,?ndmwCunrs(EketronzcaiTy Signed
(signature/
District Number 5601 Place Glens Falls, 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 _�L Place of Disposition (
(address/
°> W
(section/ CC (lot number) (grave number)
aName of Sexton or Person in Charge of Premises J r S
Z /p/ease print/
W Signature Title
DO H-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 0136 34
Receipt
r
Human remains of - ", delivered on - , 20
Pine"View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# R